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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804116
Report Date: 04/05/2024
Date Signed: 04/09/2024 11:55:09 AM


Document Has Been Signed on 04/09/2024 11:55 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:AGAPE COLLINS' CAREHOMEFACILITY NUMBER:
486804116
ADMINISTRATOR:GUBA, ALMABELLAFACILITY TYPE:
740
ADDRESS:3323 TENNESSEE STTELEPHONE:
(817) 726-2273
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
04/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:11 PM
MET WITH:Samantha Ephraim, LicenseeTIME COMPLETED:
05:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with Samantha Ephraim, Licensee. During a complaint investigation LPA discovered staff (S1) who was fingerprinted earlier in the day and had not yet obtained a clearance to this facility as required.

LPA and licensee went over info to change the Administrator and LPA will email info.

LPA also went over staff training and how to document it properly.

A civil penalty was assessed for $100.00 for staff S1 not having a fingerprint clearance to this facility.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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 04/09/2024 11:55 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: AGAPE COLLINS' CAREHOME
FACILITY NUMBER: 486804116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2024
Section Cited
CCR
87355(e)(1)

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87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
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Facility to send in written statement they understand regulation and how they will ensure they stay in compliance. Facility to self certify staff S1 will not be present until proper clearance and association is received.
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This requirement was not met as evidenced by: During today's inspection LPA found staff S1 who was fingerprinted just today and results have not been received . This is an immidiate risk to the health and safety of residents in care.
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POC due date 4/9/2024
attention LPA Canela

Civil Penalty issued for 100.00

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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