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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412239
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:44:50 PM

Document Has Been Signed on 11/19/2024 02:44 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
CCLD Regional Office,
, CA
FACILITY NAME:AGAPE CARE HOME RIVERSIDEFACILITY NUMBER:
336412239
ADMINISTRATOR/
DIRECTOR:		DARYL LEEFACILITY TYPE:
740
ADDRESS:5715 RIVERSIDE AVENUETELEPHONE:
(951) 682-1389
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
11/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Alexandra ContrerasTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martinez conducted a Case Management visit in conjunction with a complaint investigation visit with control number (8-AS-20230907150614.) LPA was greeted and granted entry into the facility by Caregiver Amelita Gragassin. Administrator Alexandra Contreras arrived shortly after.

LPA conducted a tour of the facility. LPA measured the hot water temperature in the resident bathroom which measured at 95.4 degrees F. Staff informed LPA that the hot water "takes a long time to heat up. LPA let water run for 5 minutes and hot water gradually reached a temperature of 98.4 with LPA holding the thermometer for 1 minute.

Deficiency is being cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted and a copy of this report LIC809, LIC809D and Appeal Rights were sent to email on file.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2024 02:44 PM - It Cannot Be Edited


Created By: Lydia Martinez On 11/19/2024 at 01:58 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
,
, 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 A
11/20/2024
Section Cited
CCR
87303(e)(2)

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MAINTENANCE & OPERATIONS: Hot water provided for the use of residents shall be maintained between 105-120 degrees F. The hot water measured 95.4 degrees F. This poses a risk to the Health & Safety of the residents in care.
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 Licensee to monitor water temperature for 10 days and create a water log that will be sent to LPA Martinez on 11/29/2024. Staff to check hot water temperature routinely to assure the proper water temperature is maintained at all times.

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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: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


LIC809 (FAS) - (06/04)
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