AGAPE SENIOR HOMES LLC

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made the licensee did not comply with the cited above in all resident bathrooms as water temperature measured at 121.8 to 128.8 degrees. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2026 Plan of Correction Licensee to adjust water heater temperature and provide proof to LPA by POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made the licensee did not comply with the cited above as LPAs observed a pharmacy bag with medictations left unsecured in Resident 2's bathroom. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2026 Plan of Correction Administrator corrected during visit.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations the licensee did not comply with the cited above in 1 out of 1 staff members records as records were not available for review. This poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/08/2026 Plan of Correction Administrator to send staff records for training and LIC 501 and LIC 503 for Staff 1.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the administrator did not comply with the cited above as LPAs observed an unsecured knife in couch cushion in facility den. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2026 Plan of Correction Administrator corrected during the visit.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements: (c) Admission agreements shall be signed and dated.. by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission... This requirement was not evidenced by: Based on interviews and records reveiwed, the Licensee did not ensure that an admission agreement was signed for Resident #1 within the same day period following admission per regulations. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will complete a statement of understanding regarding the regulation. The Licensee agreed to provide LPA the statement via email or fax by POC date.

Deadline recorded: May 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements: (g) Admission agreements shall specify the following: This requirement is not evidenced by: Based on interviews conducted and records reviewed, the Licensee did not ensure that the admission agreement for Resident #1 contained all the required components such as basic services, payment provisions, etc.. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will complete a statement of understanding regarding the regulation. The Licensee also stated that he will used his approved admission agreement moving forward. The Licensee agreed to provide LPA the statement via email or fax by POC date.

Deadline recorded: May 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed staff are currently living in the garage and in the den/library.

Official plan of correction

POC Due Date: 07/15/2025 Plan of Correction AD agreed for staff to remove their belongings from these areas. AD also agreed to provide a written plan to LPA stating what the living arrangements are going to be for these staff. AD agreed to provide the statement to LPA via email or fax by POC date.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

All facilities shall have a qualified and currently certified administrator... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the current listed Administrator does not have a valid certificate. LPA observed the Administrator Certificate Bureau has not received a renewal application from the current listed Administrator.

Official plan of correction

POC Due Date: 07/15/2025 Plan of Correction AD agreed to submit a written plan to LPA on how he plans to either submit a renewal application or hire an Administrator for the time being. AD agreed to submit this written plan to LPA via email or fax by POC date.

Official classification

Type A

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and review of the facility sketch, the licensee did not comply with the section cited above as one bedridden resident is observed to be located in a room that is not identified which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Licensee has scheduled an update of the fire clearance with the Fire Authority on Thursday August 15, 2024. Clarification on the location of the bedridden room and update to the facility sketch.

Official classification

Type A

Official code

87633(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and records reviewed, the licensee did not comply with the section cited above as no records of an approved hospice waiver for three residents could be located which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Licensee will locate its previous application for a hospice waiver and resubmit it for approval by the Department by the plan of corrections due date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above in as one caregiver is observed to have CPR training expired which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee will ensure all care staff are in possession of a current CPR training and provide proof of completion to LPA before the plan of corrections due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff records reviewed, the licensee did not comply with the section cited above as continued annual training was not completed by staff in 2024, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/08/2024 Plan of Correction Licensee is contracting with a new vendor after its previous vendor went out of business. Updated training and proof thereof will be conducted and provided to LPA before the plan of corrections due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff interview and records reviewed, the licensee did not comply with the section cited above as no fire and emergency drills have been conducted in the 2024 calendar year. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee will schedule quarterly drills for the remainder of the year and conduct at least one drill within the next 30 days.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation conducted during the facility visit, the licensee did not comply with the section cited above as one resident not admitted onto hospice was observed to use a bed equipped with full bed rails, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/08/2024 Plan of Correction Bed rails were substituted with half rails during the visit. Licensee to obtain physician orders for half bed rails and provide them tho the Department before the plan of corrections due date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above as three out of five physician reports were observed to be dating by more than a year for residents with established dementia diagnoses. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/08/2024 Plan of Correction Licensee has requested updates to the residents' physician reports and will provide the updated documents to the Department before the plan of corrections due date.