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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005618
Report Date: 10/01/2021
Date Signed: 10/05/2021 09:53:23 AM

Document Has Been Signed on 10/05/2021 09:53 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AGAPE ORANGE HOME IIFACILITY NUMBER:
306005618
ADMINISTRATOR:MOLDOVAN, ANDREEAFACILITY TYPE:
740
ADDRESS:502 E MEADOWBROOK AVETELEPHONE:
(714) 363-3880
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 6DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH: Care giver Esther SetyowatiTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by care giver Esther Setyowati and reason for visit was explained.

Upon entry LPA was screened per COVID guidelines. LPA tour the facility with care giver Esther Setyowati. The facility currently has 6 residents in care. Administrator Natalia Surgent arrived at the letter time. LPA observed residents watching TV in family room. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/sanitizer. LPA observed the screening/sanitizing station in the entrance of the facility. Visitors sign in and are screened for temperature. Facility takes resident temperatures daily and documents. Facility has COVID precaution postings as well as all required department postings. Facility has completed the Mitigation Plan and is approved. LPA observed adequate emergency food and water supply as well as the First Aid kit which contained all required items. Facility has all required items of PPE on site. LPA toured the outside grounds and observed ample shaded outside visitation area. Exit gate is unlocked and self latching. LPA observed the medication in locked closet. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. Staff and most residents are vaccinated for COVID-19. Resident files contained updated emergency information as well as required department forms.

Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
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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