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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881118
Report Date: 06/15/2021
Date Signed: 06/15/2021 11:29:38 AM

Document Has Been Signed on 06/15/2021 11:29 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AGAPE VILLAFACILITY NUMBER:
331881118
ADMINISTRATOR:HUNG, MARIEFACILITY TYPE:
740
ADDRESS:7027 GOLDEN VALE DRIVETELEPHONE:
(951) 255-1198
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 0DATE:
06/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Marie Hung and Daryl LeeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Jennifer Semin conducted a pre-licensing inspection. LPA met with Licensee/Administrator, Marie Hung and Daryl Lee. The application is for a Residential Care Facility for the Elderly for four (4) ambulatory residents, two (2) non-ambulatory residents and a hospice waiver for six (6).
A tour of the pending facility was conducted inside and out. Overall, the pending facility is clean and of newer construction. There is a pool in the backyard that is fenced with a locked gate and is inaccessible to residents in care. There are no firearms or ammunition. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers and tubs have grab bars and non-skid mats. The hot water temperature was measured in the residents bathroom at 114 degrees Fahrenheit. LPA observed food storage and preparation areas are clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. LPA observed a seven (7) day supply of nonperishable food and a two (2) day supply of perishable food. All appliances are clean and operating properly. There is a sufficient supply of linens, towels and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manuel. LPA observed a minimal supply of recreation and leisure items and activities but licensee states she plans to add a variety of recreation and leisure items based on their resident’s preferences, once admitted The property is completely enclosed with functioning gate to exit to the street. Outdoor space is suitable for resident use that includes a covered patio with a table and chairs. The fire extinguishers are recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. All required forms are posted in a common area.
Pre-Licensing is complete, and this facility has no deficiencies.
Ms. Hung was reminded of the statute that requires the licensee to contact LPA at CCLD 951-473-7024 within 5 business days of admitting their first resident. This notification may be done by phone, mail or fax.
An exit interview was conducted where this report was discussed and provided to Ms. Hung.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2021
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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