486804068-5-24-2024-21-AS-SMUU-D5KR4L-20240524124142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804068
Report Date: 05/24/2024
Date Signed: 05/24/2024 12:41:51 PM

Document Has Been Signed on 05/24/2024 12:41 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
SANTA ROSA RO, 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: 5	DATE:	05/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Victoria Gonzales, Administrator		TIME COMPLETED:	12:55 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	At approximately 8:30AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA rang the doorbell and knocked at the door with no answer. LPA attempted to contact Administrator, Victoria Gonzales. Staff responded and spoke through RING intercom and advised LPA they are assisting resident and will be able answer the door shortly. Staff answered door and LPA gained entrance to facility at approximately 9:00 AM. LPA was greeted by Niel Ferrer. Upon entry into the facility, LPA had temperature checked and logged. Administrator, Victoria Gonzales arrived shortly after at approximately 9:40 AM. 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 5 residents. In addition, there is 1 resident receiving hospice services and some of which with a diagnosis of dementia. At approximately 9:30 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. 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 temperature measured within regulation between 108.3 and 112.4 degrees F at three of three faucets accessible to residents. Two of two fire extinguishers inspected were charged. 8 of 8 Smoke detectors were present and last inspected on 05/20/24. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Continued on LIC809-Ca

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A MOTHER'S AGAPE HOME	FACILITY NUMBER: 486804068
	VISIT DATE: 05/24/2024

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Continued from LIC809

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. Resident was observed interacting with staff in the common area, watching television and reading for leisure. Two residents were found in there room watching television for leisure. Clients are happy, bathed daily, love the food, and enjoy the home per two clients comments and responses. LPA observed resident on hospice sleeping in their room and with staff checking on resident often.

At approximately 11:00AM, LPA reviewed 5 of 5 resident records which were all found to be well organized, thorough and contained the required documentation. At approximately 11:50 AM , LPA reviewed 4 of 4 staff records which were all found to be well organized, thorough and contained the required documentation. Medication records are thorough and contained physician's orders for each resident. One of five residents are receiving Hospice services and the Hospice care plans were up to date for the resident.

Administrator, Victoria Gonzales's Administrator Certification 6045724740 is expired as of 3/1/2024. Administrator provided LPA proof of recertification and proof Administrator Certificate is eligible and pending.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (updated with 2nd non-local evacuation site)
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Pest Prevention Services

No citations issued during today’s visit.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC809 (FAS) - (06/04)

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