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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804335
Report Date: 08/28/2026
Date Signed: 08/28/2026 04:55:25 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/28/2026 04:55 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AGAPE BACERRA CARE HOMEFACILITY NUMBER:
486804335
ADMINISTRATOR/
DIRECTOR:		RAY, SAMANTHAFACILITY TYPE:
740
ADDRESS:1011 GRANADA STTELEPHONE:
(707) 853-6271
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
08/28/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Samantha Ray-Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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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
Bethany Moellers
Star Stevenson
DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/28/2026 04:55 PM - It Cannot Be Edited


Created By: Star Stevenson On 08/28/2026 at 02:48 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGAPE BACERRA CARE HOME
FACILITY NUMBER: 486804335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2026
Section Cited
CCR
87412(a)(13)(B)

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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)
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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
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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.
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Type A
08/31/2026
Section Cited
CCR80020(a)

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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.
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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
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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.
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facility sketch indicating large 10'x12 shed usage by EOB 08/31/2026
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AGAPE BACERRA CARE HOME
FACILITY NUMBER: 486804335
VISIT DATE: 08/28/2026
NARRATIVE
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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
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AGAPE BACERRA CARE HOME
FACILITY NUMBER: 486804335
VISIT DATE: 08/28/2026
NARRATIVE
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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.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC809 (FAS) - (06/04)
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