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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804116
Report Date: 02/20/2025
Date Signed: 02/20/2025 04:25:36 PM

Document Has Been Signed on 02/20/2025 04:25 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AGAPE COLLINS' CAREHOMEFACILITY NUMBER:
486804116
ADMINISTRATOR/
DIRECTOR:		SAMANTHA RAYFACILITY TYPE:
740
ADDRESS:3323 TENNESSEE STTELEPHONE:
(817) 726-2273
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Anniemarjorie VinluanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 02/20/2025, at approximately 2:55PM, Licensing Program Analyst (LPA) Star Stevenson and Licensing Program Manager (LPM) Kimberly Mota, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA and LPM met with Annie-Majorie Vinluan-caregiver and explained the purpose of the visit.

Facility has an approved Hospice Care Waiver for three (3). Clearance is approved for six (6) non-ambulatory of which one (1) can be bedridden in bedroom #1.


At approximately 3:00PM , LPA Stevenson and LPM Mota and caregiver 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 and LPM observed the facility to be clean, in good repair and odor-free. Water faucets accessible to clients were measured and found to have temperatures of 130.6F in Kitchen and 131.1F and 127.4F in back bathrooms (pictures taken)
LPA and LPM observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with tight fitting lid. LPA and LPM observed each bedroom to have all the required furnishings, with working lights and windows with screens. One back bathroom was noted to have mold on the shower ceiling (photos taken)

Smoke detectors and carbon monoxide sensors were tested and observed to be in working order. Fire extinguisher were observed to last be inspected 12/2024 and charged. Last emergency drills were performed 10/2024
Last fire department inspection was on 01/21/2025. Facility has extra PPE and generator.

At approximately 3:30 PM the personnel roster (LIC500) was observed and all employees were deemed eligible to work at the site.

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. Repacked meets were not labeled, and bottom of freezer was dirty (photos taken)All toxins are locked and inaccessible to residents in care. LPA observed the first aid kit complete and ready for use.

Continued on LIC809-C.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AGAPE COLLINS' CAREHOME
FACILITY NUMBER: 486804116
VISIT DATE: 02/20/2025
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Continued from LIC809

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

Due to time constraints the annual inspection will need to be continued at a later date.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2025 04:25 PM - It Cannot Be Edited


Created By: Star Stevenson On 02/20/2025 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGAPE COLLINS' CAREHOME
FACILITY NUMBER: 486804116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by:
Facet water temperature measured 130.6F, 131.1F, 127.4F
Deficient Practice Statement
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87303(e)(2) Maintenance and Operation. Hot water ... shall be maintained between 105 and 120 degrees F. This requirement is not met as evidenced by: ***Based on observation of measurements conducted by LPA the
POC Due Date: 02/21/2025
Plan of Correction
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Administrator to submit a LIC 9098 self certification that hot water temperature is within regulation by POC date of 02/21/25 Additionally, Licensee to submit 7 day log of water temperature to ensure temperature is within regulation and submit to CCL by 02/28/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Mota
LICENSING EVALUATOR NAME:Star Stevenson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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