486804116-7-5-2024-21-AS-KMOA-D79UXP-20240717155840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804116
Report Date: 07/05/2024
Date Signed: 07/05/2024 05:20:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/02/2024 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240402125621

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: 5	DATE:	07/05/2024
		UNANNOUNCED	TIME BEGAN:	12:22 PM
MET WITH:	Anne Vinluan, Care staff		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of continuing complaint investigation and delivering findings, regarding the above listed allegations.

In the course of the investigation LPA conducted several interviews, made observations and reviewed records. It was alleged residents personal rights were violated in that resident R1 was being changed by staff S2, with the door closed, and R1 was heard yelling out. LPA took statements and R1 likes living in the home and the staff working are nice. Staff expressed they close the door when they change R1 because R1's room is accross from the hallway bathroom and for the residents privacy when other residents walk by. Staff expressed R1 is ok most of the time when changing and they are never rough when changing or assisting any resident.
Although the allegation may be valid, based on statements and document reviews, there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.
No citations issued today.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/02/2024 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240402125621

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: 5	DATE:	07/05/2024
		UNANNOUNCED	TIME BEGAN:	12:22 PM
MET WITH:	Anne Vinluan, Care staff		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Residents care needs are not being met.
Facility is not clean, safe, and sanitary.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of continuing complaint investigation and delivering findings, regarding the above listed allegations.

In the course of the investigation LPA conducted several interviews, made observations and reviewed records. It was alleged resident needs are not being met and that residents are only being changed once per day. LPA conducted resident and staff interviews and staff expressed that residents are changed as often as needed, residents don't usually request to be changed because staff are always checking and changing them even before residents can ask. LPA conducted resident interviews and all residents expressed they like living in this facility and they always get assistance from the staff. The 3 residents who require a diaper changed, stated they are always changed and have no complaints.

Continue report see LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240402125621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/05/2024

NARRATIVE

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LPA noticed that all bedrooms were free of odors and no urine smell. It was also alleged the facility is not clean, safe, sanitary and is in disrepair. More specifically, that there are rats, roaches and the heat does not work. LPA opened all kitchen cabinets, inspected all floors, other cabinets and LPA did not observe any droppings. The home was free of vermin. The home was also observed, clean and clutter free. Staff stated they have no issues with rodents and residents interviewed also stated they have not seen any. Residents and staff interviewed stated the home is at a comfortable temperature, they are not cold or hot, if they needed the heater turned on, the staff will turn it on. LPA was able to notice the home was at a very comfortable temperature during the previous visits and not cold and during today's visit, upon arrival LPA observed the home had the central air conditioning on to maintain the home comfortable, as the temperature outside was about 94 degrees.

Based on information received during staff and resident interviews, and LPA observations, the following allegations for Residents care needs are not being met. Facility is not clean, safe, and sanitary and Facility is in disrepair, are all found to be UNFOUNDED, meaning that the allegation is false and/or, without a reasonable basis. The above allegations are DISMISSED.

No citations issued.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

LIC9099 (FAS) - (06/04)

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