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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804116
Report Date: 02/07/2023
Date Signed: 02/07/2023 09:26:03 PM


Document Has Been Signed on 02/07/2023 09:26 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 HOMEFACILITY NUMBER:
486804116
ADMINISTRATOR:RAY, SAMANTHAFACILITY TYPE:
740
ADDRESS:3323 TENNESSEE STTELEPHONE:
(817) 726-2273
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
02/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Samantha Ray, Licensee/AdministratorTIME COMPLETED:
01:11 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 unannounced to complete this Pre-licensing inspection and go over corrections and a new fire clearance that was requested and granted by the Vallejo fire department on 1/31/2023 for 5 non ambulatory residents and a bedridden resident in room #1. This prelicensing is due to a change in ownership application that was received by Agape Collins' Care Home. LPA met with Applicant, Samantha Ray.

LPA previously 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.
The side gate has been repaired and opens easily.

Component III was conducted and completed with Applicant, Samantha Ray and management assistant, Ephraim Pajarillo on 1/20/2023.
Pre-Licensing is complete, LPA will notify Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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