Agape Bacerra Care Home

Type of visit: Annual/Random

At approximately 11:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by caregiver John Conception (S1). S1 was noted to not be associated to the facility on Guardian and it was determined that S1 was not fingerprint cleared to work, S1 indicated they had been working on and off at the facility since February 2026. Licensee indicates they thought S1 was cleared to work based on a document received on 02/12/2026 (copy retained for record) Type A violation for CCR 87412(a)(13)(B) is cited and civil penalty applied. S1 called Administrator Samantha Ray to advise of today's required inspection. Licensee arrived at approximately 11:45 AM to further assist with today's inspection. At 11:45 AM, S1 was asked to exit the property until criminal clearance is confirmed. Facility has a Fire Clearance approved for 6 non-ambulatory residents; one resident can be bedridden and served in bedroom #4 (master). The facility was also granted a hospice waiver for 3 residents. LPA was advised that facility currently has 6 residents in care all of whom were present during the inspection. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be odor free, clean and at a comfortable temperature with all doors and exits free from obstruction. Fire extinguishers found throughout the facility were charged and last inspected 11/2025. Combination smoke and carbon monoxide detectors are centrally wired and tested operation. Exits of the facility and front entrance have appropriate auditory alarm systems and found to be functioning. Water temperature at faucets accessible to residents was measured and found to be within regulation, between 105 & 120 degrees F as required by title 22 regulation. Continued on LIC809C Continue on LIC809 There was an ample supply of fresh linens, incontinence care and hygiene products available. A tour of the kitchen and food supply was inspected and found to be clean and orderly. Food items were stored properly. There was a sufficient amount of food for the number of residents in care. Cleaning supplies, laundry products and other toxins were properly secured in designated storage closets in an area secured by combination door lock. A tour of the backyard revealed a locked smaller shed with hardware supplies, as well as a newer and much taller "10'X12'" shed that is reported by licensee to have been built by resident (R1). R1 reports living in the structure noted to have a bed, dresser, table, television, clothing and personal supplies (photos taken) This 10'x12' shed has no smoke detector and was built by R1 without permits or fire clearance. A type A citation for CCR 80020(a) is cited and civil penalty assessed (See LIC809D) At approximately 12:45 PM LPA reviewed six (6) of 6 resident files and observed that all required documents were on file and licensee was advised to update Resident Appraisal and Needs Service plans now that facility has been open for 1 year. At approximately 2:15 PM LPA reviewed Guardian report for facility as of 08/27/2026 and reviewed three (3) primary caregiver records, LPA noted that evidence of 40 hours of intimal training was incomplete or off-site for two (2) of three (3) staff members and one (1) of three (3) staff, although having CPR training did not have evidence of 1st Aid training, and one (I) of three (3) staff did not have evidence of negative TB testing on-hand at the facility and Technical violations of HSC 1569.625(b)(1) - requiring 40 hours of training within the 1st 4 week of employment, CCR 87412 - requiring licensees maintain Personnel Records verification of staff training and orientation and CCR 80066(a)(11) - requiring results of Tuberculosis testing for staff members is being cited See LIC9102TV pages (3) Facility does not manage Resident money. Continued on LIC809-C Continued from LIC809-C Medicines were observed to be centrally stored and secure and facility maintains a Medicine Administration Record (MAR) Facility knows to conduct an Emergency/Disaster drill every 3 months and had a facility evacuation wide drill on 08/11/2026 LPA obtained for the facility file: updated LIC500 Personnel Roster LIC9020 Resident Roster Updated LIC610E Emergency Disaster Plan Updated Liability Insurance (good until 05/01/2027) Updated facility sketch including new 10'X12' structure on property. Document related to criminal clearance for S1 provided by licensee. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Samantha Ray- Licensee/Administrator and Appeal rights were given.the state’s words, verbatim · CDSS document, Aug 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(a)(13)(B) · Plan of correction due date: Aug 31, 2026

Criminal Clearance CCR 87412(a)13(B) (a)Licensee shall ensure...(13) For employees that are required to be fingerprinted...(B)Documentation of either a criminal record clearance or criminal record exemption as required by Section 87355 (e) This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 3 staff members which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2026

Plan of correction: Licensee is asked to self-certify they have read regulation CCR 87412(a)(13)(B) and will not allow S1 to work until criminally cleared to do so by EOB day 08/31/2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR80020(a) · Plan of correction due date: Aug 31, 2026

Fire Clearance 80020(a) (a) All facilties shall secure and MAINTAIN a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshall. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply in 1 room which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2026

Plan of correction: Licensee is asked to self-certify that they have read regulation CCR 80020(a), and to clear out a Resident built backyard shed of it's bed, pillows and living items (done during visit) as well as, submit to Community Care Licensing an updated facility sketch indicating large 10'x12 shed usage by EOB 08/31/2026

Type of visit: Prelicensing

At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility announced, for the purpose of conducting a pre-licensing inspection and met with Applicant Samantha Ray. Fire Clearance has been approved for a capacity of 6 residents; 5 of which may be non-ambulatory and 1 of which are bedridden. The facility was also granted a hospice waiver capacity of 3. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and at a comfortable temperature with all doors and exits free from obstruction. There is a shaded outdoor seating area. Fire extinguishers found throughout the facility were charged and inspected within the last 12 months. Smoke detectors and carbon monoxide detectors in resident bedrooms and throughout the facility were tested and found to be operational. Exits of the facility and front entrance have appropriate auditory alarm systems and found to be functioning. Water temperature at faucets accessible to residents was measured and found to be within regulation, between 105 & 120 degrees F. There was an ample supply of fresh linens, continence care and hygiene products available. A tour of the kitchen and food supply was inspected and found to be clean and orderly. Food items were stored properly. Residents will be provided various nutritious meals with alternate options and snacks readily available upon request with a sufficient amount of food for the number of residents in care. Cleaning supplies, laundry products and other toxins were properly secured in designated storage closets. Medications will be centrally stored and secure. Facility has generator to supply power in case of emergency. The Emergency Disaster Plan was reviewed and shows appropriate evacuation sites. Licensee will send a copy of liability insurance to CCLD once Licensed. Component III orientation was conducted with the Applicant. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided.the state’s words, verbatim · CDSS document, Aug 11, 2025