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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005618
Report Date: 08/21/2024
Date Signed: 08/21/2024 12:06:50 PM

Document Has Been Signed on 08/21/2024 12:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AGAPE ORANGE HOME IIFACILITY NUMBER:
306005618
ADMINISTRATOR/
DIRECTOR:
MOLDOVAN, ANDREEAFACILITY TYPE:
740
ADDRESS:502 E MEADOWBROOK AVETELEPHONE:
(714) 363-3880
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 6DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Natalia SurgentTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit before entering the facility. Staff called Licensee/Administrator (AD) Natalia Surgent who arrived and was present for the remainder of the visit. AD Surgent has a current administrator’s certificate that expires 02/10/26.

Around 9:00am LPA Haley began the tour of the facility with. Right next to the front door is a lock closet used to store staff files, resident files, resident medications, and a first aid kit with all the required elements.

All six clients were present during the visit. All resident bedrooms were clean, well organized, and had all necessary requirements: nightstand, chair, lamp and storage space. Resident bathrooms were clean and organized. Hot water temperature was measured in the range of 109.5 – 111.5 degrees Fahrenheit.

There’s a small office area in the living room with a filing cabinet with files of former employees and former residents. Dominoes and other activity items were observed right behind desk in the office area. There’s a fully charged fire extinguisher mounted on the wall right behind the office area.

The kitchen was clean and organized. All knives and sharp objects were locked in a cabinet near the stove. All burners on the stove were operational. The facility has a two-day supply of perishable food items and seven-day supply of nonperishable food items.

The garage has clear walking paths and is used to store various facility items. Hazardous chemicals are locked in a cabinet in the garage. There’s a laundry area with a washer and dryer, and an additional deep freezer and refrigerator with an additional food supply. An emergency supply of water was observed.

Continued on LIC809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AGAPE ORANGE HOME II
FACILITY NUMBER: 306005618
VISIT DATE: 08/21/2024
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The backyard was clean, organized, and walkways are free of obstruction. There’s a shaded patio with a couple tables and chairs. There’s a locked shed used to store miscellaneous items. The side exit gate is self-closing and self-latching.

During the visit, interviews were conducted with two staff, and one resident. A file review and medication audit was conducted for six residents, and four staff files were reviewed.

No bodies of water observed. Smoke and carbon monoxide detectors tested and are operational. Two fully charged fire extinguishers were observed mounted on the wall in different areas of the facility.

No deficiencies are being cited during today’s visit. An exit interview conducted, and a copy of the report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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