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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005232
Report Date: 09/28/2022
Date Signed: 09/28/2022 12:32:31 PM

Document Has Been Signed on 09/28/2022 12:32 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 COTTAGE IXFACILITY NUMBER:
306005232
ADMINISTRATOR:NICOLAS OUDINOTFACILITY TYPE:
740
ADDRESS:17332 MELBOURNE LNTELEPHONE:
(909) 534-0132
CITY:YORBA LINDASTATE: CAZIP CODE:
92887
CAPACITY: 6CENSUS: 6DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Frances Mejia - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Agape Cottage IX. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on Infection Control. LPA Velazquez was allowed entry into the facility and met with Caregiver (CG) Maycelina Dagdag. Caregiver Dennis Dagdag was also present. Administrator (Admin) Frances Mejia arrived shortly after LPA's arrival. The facility is licensed for 6 non-ambulatory residents of which 1 may be bedridden. The facility also has a Hospice waiver for 6 residents. There are currently 6 residents living in the facility and 5 residents are diagnosed with Dementia. LPA Velazquez provided Administrator Mejia the PIN so that the facility's overdue annual fees could be paid at the time of this visit. Administrator Mejia provided LPA Velazquez with proof of payment of the annual facility fees.

At 10:56 AM LPA Velazquez conducted a tour of the physical plant along with Admin Mejia. The 1 story home consists of 4 resident bedrooms with 2 bathrooms and 1 staff bedroom. The facility also has a living room, family room, dining area, and kitchen. The facility had a variety of COVID-19 postings throughout the facility. The facility also had a sign in area where temperature is checked and PPE available. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA and Admin observed full bed rails on the bed of one resident and per Admin the resident is not receiving hospice services. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 119.1 degrees Fahrenheit in the first bathroom and at 117.8 degrees Fahrenheit in the second bathroom which Administrator Mejia verified. Handwashing instructions were posted in the bathrooms with soap and paper towels available in each bathroom.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 COTTAGE IX
FACILITY NUMBER: 306005232
VISIT DATE: 09/28/2022
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LPA Velazquez inspected the kitchen along with Administrator Mejia. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. Two bottles of Over The Counter (OTC) supplements were located on the door of the refrigerator door easily accessible to residents which Admin verified. LPA and Admin observed the knives and other sharps were stored in a locked drawer in the kitchen and inaccessible to residents. LPA and Admin observed the dishwasher was inoperable which Admin verified. LPA and Admin observed the oven with excessive grease stains which Admin verified. Resident medications were stored in a locked closet located in the kitchen. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. The auditory alarms throughout the facility were in operating condition.

LPA Velazquez along with Administrator Mejia toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. There were several items in the back yard patio next to the table where residents sit such as a gas can with gasoline, a generator, rusty shovels, rusty garden tools, broken chair, old walker, bed rails, cardboard, and wheelchairs which Admin verified. The exit gate did not have a self-closing latch. There were no security bars or weapons on the premises.


No resident or staff files were reviewed at the time of this visit and a resident medication review was not conducted as this inspection focused primarily on Infection Control.


Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Francis Mejia and a copy of this report along with the appeal rights and a copy of the LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/28/2022 12:32 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 09/28/2022 at 11:51 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AGAPE COTTAGE IX
FACILITY NUMBER: 306005232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2022
Section Cited
CCR
87705(f)(2)

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Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: based on observation & interview the Licensee did not ensure the gasoline can with gasoline, OTC supplements & rusty tools were made inaccessible to residents which poses an immediate risk to the health and safety of residents.
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The Licensee to ensure all items that pose a risk to residents with Dementia be made inaccessible and submit written proof to LPA by POC due date. Licensee to submit a written statement to LPA indicating how they intend to adhere to this regulation by POC due date.

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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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022


LIC809 (FAS) - (06/04)
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