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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701151
Report Date: 07/11/2023
Date Signed: 07/11/2023 12:10:44 PM

Document Has Been Signed on 07/11/2023 12:10 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AGCAOILI RESIDENTIAL CARE HOMEFACILITY NUMBER:
342701151
ADMINISTRATOR:AGCAOILI JR., RUSTICOFACILITY TYPE:
735
ADDRESS:8042 BROUILLY COURTTELEPHONE:
(916) 698-8342
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 4CENSUS: 3DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rustico AgcaoiliTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection on 7/11/2023. LPA met with Administrator, Rustico Agcaoili Jr. and explained the purpose of today’s visit.

Administrator holds current certificate # 6033898735 and expires on 10/1/2024. The facility is licensed for 3 ambulatory residents and 1 non-ambulatory resident. The facility currently has 3 clients residing at the home at this time. Administrator will assist LPA with today’s inspection.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. The hot water temperature was observed to be 105.8 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 74 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. Proof of current liability insurance was observed. Proof of current liability insurance was observed. A full Care Tool Inspection was completed at facility.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AGCAOILI RESIDENTIAL CARE HOME
FACILITY NUMBER: 342701151
VISIT DATE: 07/11/2023
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LPA requested client and staff files for review. LPA reviewed (3) client files and (2) staff files, including criminal record clearances. LPA reviewed staff associations to the facility. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents was obtained during today's visit:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, LIC 610 Emergency Disaster Plan, Administrator Certificate, and Proof of Current Liability Insurance.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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