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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000395
Report Date: 09/16/2024
Date Signed: 09/16/2024 10:43:55 AM


Document Has Been Signed on 09/16/2024 10:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:AGUSTIN CARE HOMEFACILITY NUMBER:
347000395
ADMINISTRATOR:AGUSTIN, MARIAFACILITY TYPE:
740
ADDRESS:9166 SEBASTIANI WAYTELEPHONE:
(916) 896-1974
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 4DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria Agustin - AdministratorTIME COMPLETED:
11:15 AM
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On 9/16/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a required - 1 Year inspection visit. LPA met with Administrator Maria Agustin and explained the purpose of the visit.

Administrator certification expires on 3/19/2025. The facility is licensed to serve up to 6 ambulatory residents. Current census is 4. LPA toured the facility with Maria Agustin.

LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident 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 required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 109.9*F which was within the required range of 105-120*F. The temperature inside the facility measured at 74*F which was within the required range of 68-85*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair.

LPA requested resident and staff files for review. LPA reviewed (2) staff files and (3) resident files, including criminal record clearances. 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.

The following forms and documents were obtained:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed. An exit interview was conducted, and a copy of this report was provided to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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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