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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412239
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:34:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230907150614
FACILITY NAME:AGAPE CARE HOME RIVERSIDEFACILITY NUMBER:
336412239
ADMINISTRATOR:DARYL LEEFACILITY TYPE:
740
ADDRESS:5715 RIVERSIDE AVENUETELEPHONE:
(951) 682-1389
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 6DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alexandra ContrerasTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to gather additional information and deliver the findings on allegation listed above. LPA introduced herself to Administrator (AD) Alexandra Contreras and explained the purpose of today's visit.

During the course of the investigation, LPA toured the facility and interviewed staff. Allegation that "facility is in disrepair"; residents are being showered with buckets due to the shower not working properly. The investigation revealed the following: During the tour of the facility, LPA observed a bucket full of water and shower head leaking inside bucket (picture taken). AD acknowledged shower valves and shower head need to be repaired/replaced. Hot water was tested at 95.4 degrees F. The rest of the facility appears clean, safe, and sanitary. Based on observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Exit interview conducted with AD and copy of this report LIC9099, LIC9099D, and Appeal Right will be sent to email on file.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20230907150614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: AGAPE CARE HOME RIVERSIDE
FACILITY NUMBER: 336412239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Per staff, valves and shower head need to be replaced which consist of breaking the wall that connects to Resident's room. Licensee to submit plan to LPA Martinez by POC due date of 11/20/2024 on noted areas.
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Based on observation, Licensee failed to ensure facility is in good repair. LPA observed leaking shower head, and shower handle valves need to be replaced per AD. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230907150614

FACILITY NAME:AGAPE CARE HOME RIVERSIDEFACILITY NUMBER:
336412239
ADMINISTRATOR:DARYL LEEFACILITY TYPE:
740
ADDRESS:5715 RIVERSIDE AVENUETELEPHONE:
(951) 682-1389
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 6DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alexandra ContrerasTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff is serving food that is not of quality
Staff is serving undercooked food to resident in care
INVESTIGATION FINDINGS:
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The investigation into allegations that, staff is serving food that is not of quality and staff is serving undercooked food to the residents. The investigation revealed the following. Four of six residents interviewed stated they like the food that staff make and had no complaints. Staff interviewed and the Administrator (AD) reported that they have not received any complaints on food from the residents and residents likes on food are acknowledged and pleased. LPA observed a 7 day of non-perishable food and 2 days of perishable food. AD stated she does the grocery shopping on Tuesdays. LPA observed lunch was prepared and served during today’s visit which consisted of a bowl of shredded beef and vegetable soup with fruit, avocado, and jello on the side for two residents. Two other residents were served cut up pizza rolls, fruit, smashed potatoes, and jello and one resident was served a cut up ham cheese sandwich, fruit, and jello and to drink they had juice. Dinner will be grilled cheese and chicken soup. There is no evidence to support the allegations above, therefore the allegations are deemed Unsubstantiated, although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with AD Contreras and a copy of this report was sent to email on file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3