486804116-1-26-2024-21-AS-JBOS-CZUPCN-20240126101214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804116
Report Date: 01/25/2024
Date Signed: 01/26/2024 10:13:36 AM

Document Has Been Signed on 01/26/2024 10:13 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
SANTA ROSA RO, 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: 6	DATE:	01/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator- Almabella Guba		TIME COMPLETED:	05:15 PM

NARRATIVE

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On 01/25/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Samanth Raty, and explained the purpose of the visit.

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.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed each bedroom to have all the required furnishings, with working lights and windows with screens.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. Facility medications are locked and inaccessible to residents in care. All toxins are locked and inaccessible to residents in care. Hot water temperature was measured above regulation. LPA observed the first aid kit complete and ready for use.

LPA reviewed a total of six (6) residents' files and three (3) staff files. Three of three staff files observed did not have completed TB testing.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.

An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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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Document Has Been Signed on 01/26/2024 10:13 AM - It Cannot Be Edited

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: AGAPE COLLINS' CAREHOME	FACILITY NUMBER: 486804116
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in the water was measured in three locations above the regulation tempeture requirement which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	Administrator will turn the water heater down and regularly monitor the tempeture of the water.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/26/2024 10:13 AM - It Cannot Be Edited

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: AGAPE COLLINS' CAREHOME	FACILITY NUMBER: 486804116
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in three out of three staff files reviewed were missing the health screening with a completed TB test which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/01/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that all staff have a completed health screening and TB screening before the employee begin working at the facility. Admin will complete a plan to ensure this doesnt occur in the future and share this plan with the LPA via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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