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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920182
Report Date: 03/05/2025
Date Signed: 03/05/2025 04:32:36 PM

Document Has Been Signed on 03/05/2025 04:32 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AGAPE VILLA CARE HOMEFACILITY NUMBER:
315920182
ADMINISTRATOR/
DIRECTOR:
DHALIWAL, HARDEEPFACILITY TYPE:
740
ADDRESS:3594 OLD COUNTRY CTTELEPHONE:
(916) 771-6941
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 4DATE:
03/05/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Joanna (Jo) Nebeker and Hardeep DhaliwalTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 3/5/2025 LPA Tryon visited the facility to do a pre-licensing visit. LPA met with applicant Hardeep Dhaliwal and Administrator Joanna Nebeker. The application is for a change of ownership, and there are currently 4 residents living at the facility.

LPA toured the facility with applicant and Administrator including common areas, kitchen, dining areas, bedrooms, bathrooms, hallways, laundry room, garage, medication storage, food storage, and yard. The facility is very spacious, well-kept and nicely decorated. Bedrooms are spacious with required furnishings. There are 6 private bedrooms, 6 bathrooms. Food supplies are appropriate for 7 days perishable and 2 days non-perishable. Food was fresh and varied. Kitchen was well-equipped and clean. There is a fireplace but it is covered; and is turned off (gas fireplace). Kitchen stove is made inaccessible to residents. Sharp items, etc are locked. Cleaners/chemicals are locked. Medications are centrally stored and locked. The house is very organized and neat. Combination smoke detector/carbon monoxide detectors are installed. Fire extinguisher present and charged. First Aid supplies present and appropriate, first aid manual present. Facility maintains records for residents including required documents; and staff files. Appropriate documents are posted including personal rights, contact information for CCL, Ombudsman, etc.
There is an in-ground swimming pool in the back yard, which has a tall iron fence and locked gates.

LPA reviewed the Pre-licensing Care Tool with Applicant and Administrator.

LPA also reviewed the RCFE Orientation Component III with Applicant and Administrator. At this point the Orientation has been completed.

At this time the facility appears to be in substantial compliance with the regulations. No deficiencies were cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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