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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005218
Report Date: 05/23/2022
Date Signed: 05/23/2022 03:04:50 PM

Document Has Been Signed on 05/23/2022 03:04 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AGAPE ORANGE HOMEFACILITY NUMBER:
306005218
ADMINISTRATOR:SURGENT, NATALIAFACILITY TYPE:
740
ADDRESS:816 E MEATS AVETELEPHONE:
(714) 366-1858
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 6DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Natalia Surgent, AdministratorTIME COMPLETED:
03:05 PM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Caregiver (CG) Debbie Longkutoy. LPA Rosie Quiroz explained the nature of the visit. Administrator Natalia Surgent arrived shortly after. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Age range 60 and over, 6 Non Ambulatory residents, and has a Hospice Waiver for 3 residents. Facility currently providing services to two residents on hospice. Administrator Natalia Surgent has a current Administrator certificate with expiration date of February 9, 2024.
On or about 1:57pm, LPA Rosie Quiroz along with (CG) Debbie Longkutoy began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed one of six residents in their bedroom resting, and five of six residents observed to be resting and watching television in living-room area supervised by caregivers. LPA Quiroz interacted and interviewed with resident's during today's visit. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 78 degrees fahrenheit.
All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 110 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and kitchen area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area for residents and visitor's enjoyment in backyard and front porch area. The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on May 18, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated May 18, 2021.
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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AGAPE ORANGE HOME
FACILITY NUMBER: 306005218
VISIT DATE: 05/23/2022
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 LPA Quiroz was informed that all residents and staff have had their COVID-19 vaccinations and first Booster and will be speaking to resident's families about second booster vaccination. Facility indicated to be recording resident's temperatures daily.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

This report was reviewed with (AD) Natalia Surgent, and a copy of this report and LIC 811 Confidential Names were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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