486804068-6-22-2023-21-AS-DTOA-CT2VUB-20230622164427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804068
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:44:32 PM

Document Has Been Signed on 06/22/2023 04:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	A MOTHER'S AGAPE HOME		FACILITY NUMBER:	486804068
ADMINISTRATOR:	GONZALES, VICTORIA		FACILITY TYPE:	740
ADDRESS:	657 CANTERBURY CIR		TELEPHONE:	(707) 689-5807
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	6	CENSUS: 6	DATE:	06/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:32 PM
MET WITH:	Neil Ferrer, Lead Staff		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/22/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Lead Staff, Neil Ferrer. Administrator, Victoria Gonzales was contacted but was unable to meet at the time of visit. The facility is a single story home licensed for six non-ambulatory residents and a hospice waiver capacity of 6. The facility currently provides care for 6 residents, 1 of which was admitted to the hospital during the time of visit. In addition, there are 0 residents are receiving hospice services and some of which with a diagnosis of dementia. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead staff; Neil Ferrer, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 4/27/2023 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were also tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the facility laundry room and garage. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen pantry. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and measured between 105.2 and 105.8 degrees F which is within regulation. Continued onto LIC809-Ca

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A MOTHER'S AGAPE HOME	FACILITY NUMBER: 486804068
	VISIT DATE: 06/22/2023

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Medications located in designated closet were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Facility receives medication deliveries direct from pharmacy. Resident were observed interacting with staff in the common area, watching game show television or reading books for leisure. There are two emergency exits located in the backyard both of which were found to be unobstructed. All auditory alarms leading out of the facility send a chime to the front room and common area were all found to be in working order.

LPA conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPA also conducted a file review for all residents. Upon review, LPA found that resident (R1) requires an updated Needs & Service Plan completed. There have not been any major changes of condition and R1 has attended physician's visits in the past several months however documents need updating. Technical Violation issued. Administrator agrees to update forms and submit to CCLD. In addition, during the tour LPA observed a large pair of scissors found on top of resident (R2)'s closet. LPA found that R2 is non-ambulatory and unable to stand without assistance and that the scissors are not easily accessible to R2. Staff explained to LPA that R2's family member had brought and used the scissors and that R2 does not use or cannot reach the item. Scissors were immediately removed. Technical Violation issued.

Administrator, Victoria Gonzales's Administrator Certification 6045724740 is valid through 3/1/2024.

LPA requested the following documents be sent to CCL by COB 7/22/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

No deficiencies cited during today's visit.
No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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