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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203297
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:50:07 PM

Document Has Been Signed on 10/06/2021 01:50 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ROGERS AGAPE CARE HOMEFACILITY NUMBER:
547203297
ADMINISTRATOR:ROGERS, WILLIAM KEITHFACILITY TYPE:
735
ADDRESS:1206 W. NORTH GRANDTELEPHONE:
(559) 781-4055
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 5DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Keith Rogers
Sharon Rogers		TIME COMPLETED:
01:53 PM
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Today, Licensing Program Analyst (LPA) M, Medina conducted an unannounced Infection Control Inspection. LPA allowed entrance by Licensee Sharon Rogers. LPA completed the contact questionnaire prior to entrance into the facility. LPA conducted inspection with both Licensee Keith and Sharon Rogers.

Infection control procedures described in written and observed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), visitation policy, and quarantine/isolation procedures, surveillance testing, infection control. Facility has adequate PPE available which includes, gowns, gloves, hand sanitizers, N-95 and face shields. Facility has a binder for COVID for procedures, documentation, postings and communication.

LPA observed carbon monoxide and smoke detectors present and observed operational during today's inspection. Fire extinguisher has a service date of 4/23/2021 . Facility has a 7-day supply of non-perishable and 2-day supply of perishable foods on site. Facility has 2 shared rooms and 1 private room, shared rooms have beds that are 6 feet apart. Bathrooms are fully stocked with soap, and paper towels. LPA observed a 30 day supply of resident medications.

LPA observed the required infection control practices to be in compliance.

No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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