306006346-7-27-2023-22-AS-DLMN-CU5VNG-20230727163508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006346
Report Date: 07/26/2023
Date Signed: 07/27/2023 04:36:02 PM

Document Has Been Signed on 07/27/2023 04:36 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	AGAPE LUXURY HOME		FACILITY NUMBER:	306006346
ADMINISTRATOR:	MOLDOVAN, ANDREEA		FACILITY TYPE:	740
ADDRESS:	1963 MCCORMACK LN, B		TELEPHONE:	(714) 366-5777
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY: 6		CENSUS:	DATE:	07/26/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Andreea Moldovan - Administrator		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 9:00am and was greeted and granted entry by designated Administrator (AD) Andreea Moldovan. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (2) ambulatory, (3) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 2/28/2023. Structure: The facility is located in a home behind the Administrator’s residence. The back house was built prior to AD moving in. AD showed LPA the permit allowing for two houses to be built on the same lot. LPA observed a sign on the fence nearest to the sidewalk directing facility residents and facility visitors to the back house. LPA obtained photos of the outside of the back house. The facility is a one-story home with three resident bedrooms, two bathrooms, living room, kitchen, dining room and outdoor seating areas. There are three seating areas outside between the facility and the AD’s residence. One of these seating areas is shaded. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room. There are two exit gates on each side of AD’s residence. LPA observed these exits to be accessible from the facility. LPA did not observe any obstacles or hazards leading to the outdoor exits or outside of the facility. Client Bedrooms: All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. There is auditory signal sent out whenever one of the doors leading outside of the house is opened. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in cabinets under the sink the bathroom and kitchen.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AGAPE LUXURY HOME	FACILITY NUMBER: 306006346
	VISIT DATE: 07/26/2023

NARRATIVE

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Medications, First-Aid Kit & Book: Medication will be stored in a locked drawer in the kitchen. First aid kit is stored in a cabinet in the kitchen. The first aid kit has all the required elements.

Resident & Staff Files: Records will be kept in a cabinet near the check-in station.

Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a receipt of purchase for the fire extinguisher which indicates the fire extinguisher was purchased on 5/7/23.

Reading Material, Games, Equipment & Materials: The facility has activity materials that will be kept in the TV stand in the living room. Puzzles, Bingo, card games, other games and books will also be kept for resident use.

Fire clearance: Was approved by a fire inspector of City of Placentia Fire Department on 05/15/2023.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Signal System: The facility utilizes a signal system. Each resident has their own button with a lanyard. When pressed, the system emits a sound. The monitor displays a number indicating which specific resident pressed the signal button. The monitor is kept on a kitchen counter.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 110.3 degrees Fahrenheit in the bathroom along the hallway closest to the living room and 111 degrees Fahrenheit in the bathroom in the shared room.

Linens & Hygiene Supplies: A supply of extra linen was stored in cabinets in the hallway.

Emergency Phone Numbers, Exit Plan & Menu: An emergency disaster plan with means of exiting, emergency phone numbers and Menus are all posted.

Food Service: There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AGAPE LUXURY HOME	FACILITY NUMBER: 306006346
	VISIT DATE: 07/26/2023

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Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational. The door from the living room to the hallway is a fire door that automatically closes when smoke/fire is detected. The door tested operational and does not lock, allowing for staff and residents to pass through the doorway if necessary in an emergency.

Appliances: Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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