486804116-4-20-2023-21-AS-ACAA-CR3S3Y-20230420133154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804116
Report Date: 04/18/2023
Date Signed: 04/20/2023 01:32:04 PM

Document Has Been Signed on 04/20/2023 01:32 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' CAREHOME		FACILITY NUMBER:	486804116
ADMINISTRATOR:	GUBA, ALMABELLA		FACILITY TYPE:	740
ADDRESS:	3323 TENNESSEE ST		TELEPHONE:	(817) 726-2273
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 4	DATE:	04/18/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	11:22 AM
MET WITH:	Ephraim Pajarillo		TIME COMPLETED:	02:08 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) Araceli Canela arrived unannounced to conduct a Post Licensing visit, at about 11:25 am on 4/18/2023, and met with care staff, Roland Elan. Co-Administrator, Ephraim Pajarillo arrived a few minutes later. There are currently four(4) residents in care. Facility has an approved Hospice Care Waiver for three(3). Facility has submitted the required Infection Control Plan. Fire clearance is approved for six(6) non-ambulatory of which one(1) can be bedridden in bedroom #1. All resident files were reviewed, and found to be complete. LPA reviewed staff files, including training. All staff have criminal record clearance as required. All staff are first aid and CPR certified. Caregivers are trained to assist residents with medication. Smoke detectors and carbon monoxide detectors were found to be operational at the time of the inspection. Hot water temperature measured at 115 degrees and Hot water temperature is within acceptable range of 105-120 degrees F. LPA toured the facility with the Care staff, Roland Elan. The home was found to be clean and orderly, at a comfortable temperature and with all exit free from obstruction. There was a sufficient supply of both perishable and non-perishable foods. LPA observed a sufficient supply of hygiene products, and linens available. There is outdoor space for activities. Emergency Disaster plan was discussed with the Administrator. Continued on LIC809C...

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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' CAREHOME	FACILITY NUMBER: 486804116
	VISIT DATE: 04/18/2023

NARRATIVE

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Facility medications are locked and inaccessible to residents in care. All toxins are locked and inaccessible to residents in care. All bathrooms have grab bars, non-slip flooring and/or mats for resident use as needed. There was sufficient lighting in resident rooms, bathrooms and hallways.

Facility had a sufficient supply of personal protective equipment(PPE) for staff use as needed.

LPA requested the following documents to be submitted to CCL by 5/10/2023
LIC500
LIC9020
LIC308
Copy of Liability Insurance
Updated infection Control Plan of Operation

No deficiencies cited today.
Exit interview conducted.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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