486804116-1-23-2023-21-AS-ACAA-CNCS73-20230123123652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804116
Report Date: 01/20/2023
Date Signed: 01/23/2023 12:37:23 PM

Document Has Been Signed on 01/23/2023 12:37 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:	AGAPE COLLINS' CARE HOME		FACILITY NUMBER:	486804116
ADMINISTRATOR:	RAY, SAMANTHA		FACILITY TYPE:	740
ADDRESS:	3323 TENNESSEE ST		TELEPHONE:	(817) 726-2273
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 6	DATE:	01/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Samantha Ray		TIME COMPLETED:	03:45 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	Licensing Program Analyst (LPA) A. Canela, arrived unnanounced to conduct this Pre-licensing inspection due to a change in ownership application that was received for Agape Collins' Care Home. LPA met with Applicant, Samantha Ray and management assistant, Ephraim Pajarillo. The facility received a fire clearance approval on 11/10/2022 for total capacity of 6 residents, of which 3 can be non ambulatory and 3 ambulatory. The applicant will submit a corrected LIC200 and facility sketch for corrected changes and a new Fire clearance will be requested for approval of all resident rooms to be approved for non-ambulatory and a possible bedridden room . LPA toured facility and observed: Facility is a one floor residence, with a total of 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, dinning room, kitchen, and laundry area. The facility was observed to be clean. All bedrooms were observed to have the required furnishings, such as a bed, night stand, dresser, lamp, chair and required linens. Hallways were observed with night-lights for the safety of the residents. There is an ample supply of personal hygiene products, extra bedding, towels and linens. The refrigerator was observed to be clean and there was plenty of perishable and Non perishable foods that appeared to be in good condition. Cleaning supplies are locked and not accessible to residents. The facility has a first aid kit available. Personnel records and clients records are stored in locked cabinet. LPA observed there are several binders labeled and organized with facility records. Medications are kept locked and inaccessible to residents. The facility has an emergency binder with clients information. Report continued on LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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: AGAPE COLLINS' CARE HOME	FACILITY NUMBER: 486804116
	VISIT DATE: 01/20/2023

NARRATIVE

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Smoke detector and carbon monoxide detectors are operational. LPA observed 2 Fire extinguishers that were charged and serviced on 3/17/2022. Water temperature was tested by the administrator and found to be at 119.1 and within the required regulation of 105-120 degrees f.
LPA toured the yard, and observed it to be clean, with patio furnishings available to residents. Facility postings and the required COVID-19 postings for the facility were observed.

Component III was conducted and completed with Applicant, Samantha Ray and management assistant, Ephraim Pajarillo.

Pre-Licensing is NOT complete, and this facility will need to submit corrections of LIC200 and New facility sketch for ambulatory room changes and Fire Clearance approval, prior to licensure. Facility to correct side gate, so that it opens properly and easily. Once CCL receives updated sketch and fire clearance is approved, LPA will notify Application Unit so application process may proceed.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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