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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005993
Report Date: 02/14/2025
Date Signed: 02/14/2025 05:09:27 PM

Document Has Been Signed on 02/14/2025 05:09 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 SENIOR IIFACILITY NUMBER:
306005993
ADMINISTRATOR/
DIRECTOR:		SURGENT, COSMINFACILITY TYPE:
740
ADDRESS:4730 EAST MAYCHELLE DRIVETELEPHONE:
(714) 366-5468
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 6CENSUS: 6DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Caregiver Tinny LengkeyTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On February 14, 2025, at 12:00pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Tinny Lengkey. Assistant Administrator (AA) Natalia Surgent arrived at the facility around 12:30pm and LPA Kim explained the purpose of the visit. AA Surgent could not stay for the visit and said that CG Lengkey could sign on their behalf

The facility is licensed to operate for five (5) nonambulatory residents, of which 1 may be bedridden, and has a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: one (1) staff bedroom, six (6) resident bedrooms, four (4) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with AA Surgent. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5, and Resident Room 6. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 114.8 degrees F to 116.2 degrees F. A comfortable temperature of 78 degrees F was maintained in the facility.

LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AGAPE SENIOR II
FACILITY NUMBER: 306005993
VISIT DATE: 02/14/2025
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-602-6576) remains available. Last emergency drill was conducted on January 9, 2025, and is conducted quarterly. First aid kit is maintained and contains all the necessary elements. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has two (2) fire extinguisher that are charged and mounted in the garage and in the dining room.

LPA Kim conducted an audit of resident files (R1-R6), staff files (S1-S6), and medication and medication administration record were in all in order and complete.

A deficiency was cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed the following deficiency: there is an enclosed room with two built walls used for storage in the garage that was not in the facility sketch.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Caregiver Tinny Lengkey.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
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Document Has Been Signed on 02/14/2025 05:09 PM - It Cannot Be Edited


Created By: Edward Kim On 02/14/2025 at 04:44 PM
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 SENIOR II
FACILITY NUMBER: 306005993

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, photos, interviews, and record review, the licensee did not comply with the section cited above. LPA observed there is an enclosed room with two built walls in the garage that is not in the facility sketch. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee states they will go and obtain building permit, or approval, from Anaheim Building Department of the enclosed room with two built walls. They will send proof to CCLD via email to Edward.Kim@dss.ca.gov by POC due date February 28, 2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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