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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601346
Report Date: 12/14/2023
Date Signed: 12/14/2023 01:30:51 PM


Document Has Been Signed on 12/14/2023 01:30 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AGAPE ASSISTED LIVINGFACILITY NUMBER:
075601346
ADMINISTRATOR:TRIF, LUCIANFACILITY TYPE:
740
ADDRESS:1841 ANDREA LANETELEPHONE:
(925) 788-2530
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 6DATE:
12/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lucian Trif, AdminsitratorTIME COMPLETED:
01:45 PM
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On 12/14/2023 at 12:50 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Lucian Trif, Administrator.

LPA came to discuses the incident report that was submitted to the department on 12/05/2023. This report stated that one of the residents had a fall and needed medical attention. Licensee explained the timeline of events and showed the LPA what actions they have taken to mitigate the situation in the future.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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