<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804116
Report Date: 11/17/2022
Date Signed: 11/17/2022 10:59:29 AM


Document Has Been Signed on 11/17/2022 10:59 AM - 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:AGAPE COLLINS' CARE HOMEFACILITY NUMBER:
486804116
ADMINISTRATOR:RAY, SAMANTHAFACILITY TYPE:
740
ADDRESS:3323 TENNESSEE STTELEPHONE:
(817) 726-2273
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: DATE:
11/17/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:SAMANTHA RAY & ALMABELLA GUBAApplicant/administrator TIME COMPLETED:
10:30 AM
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
Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): YES (6)

Method: Telephone call with CAB
COMP II Participants:SAMANTHA RAY & ALMABELLA GUBAApplicant/administrator
Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1.Facility operation: License type, client/resident populations, and program
2.Staff qualifications and responsibilities
3.Applicant and Administrator qualifications
4.Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5.Grievances, Complaints, Community resources
6.Physical plant, food service
7.Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

8. Discussed the COVID-19 Mitigation Plan & PIN emailed

SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Maria EjazTELEPHONE: (916) 651-7844
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1