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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708695
Report Date: 12/26/2024
Date Signed: 12/27/2024 08:19:27 AM

Document Has Been Signed on 12/27/2024 08:19 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AGAPE OF CARMELFACILITY NUMBER:
270708695
ADMINISTRATOR/
DIRECTOR:		FICKEWIRTH, MIRIAMFACILITY TYPE:
740
ADDRESS:25527 FLANDERS DRIVETELEPHONE:
(831) 626-1032
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY: 6CENSUS: 6DATE:
12/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Administrator Miriam FickewirthTIME VISIT/
INSPECTION COMPLETED:
02:57 PM
NARRATIVE
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On 12/26/2024, LPA V Gorban visited the facility to conduct case management revealed during complaint investigation.

During this visit LPA questioned Administrator regarding incident report provided by staff on 08/16/2024 regarding Resident 1 (R1). Based on staff and administrator interviews resident (R1) fall incident was not reported to Fresno Licensing Office.

During the complaint investigation, administrator interview and records review of Guardian and Licensing Information System shows S2 is not associated to the facility while providing care to residents during the days of 8/14/2024 to 08/18/2024.

Deficiency for both events cited on the attached LIC809-D in accordance with California Code of Regulations, Title 22,


Division 6 and an immediate civil penalty is being assessed in the amount of $500.

An exit interview was conducted with Administrator Miriam Fickewirth.

Appeal Rights provided. Report signed on-site by Administrator, whose signature on the form confirms receipt with of this document.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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 12/27/2024 08:19 AM - It Cannot Be Edited


Created By: Vadim Gorban On 12/26/2024 at 11:12 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AGAPE OF CARMEL
FACILITY NUMBER: 270708695

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2024
Section Cited
CCR
87355(a)

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87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment....This requirement was not observed as evidenced by:
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The facility administrator ensure to follow Licensing requirements and staff that is not cleared to be present at the facility is no longer there.
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The facility Administrator failed to follow regulations requirements by ensuring 1 out of 2 staff members is cleared and associated to the facility roster. This poses immediate health and safety risk to persons in care.
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Type B
12/30/2024
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited....
This requirement was not observed as evidenced by:
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The facility administrator will review Licensing regulation and ensure all incident reports to be provided to Fresno Licensing Office by fax or email.
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The facility administrator failed to follow Licensing regulation by providing written report for incident hat occurred on 08/16/24 to Licensing Agency, which poses potential health and safety risk to persons in care
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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:Brenda Chan
LICENSING EVALUATOR NAME:Vadim Gorban
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
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