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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000395
Report Date: 09/10/2026
Date Signed: 09/10/2026 12:43:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/10/2026 12:43 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AGUSTIN CARE HOMEFACILITY NUMBER:
347000395
ADMINISTRATOR/
DIRECTOR:		AGUSTIN, MARIAFACILITY TYPE:
740
ADDRESS:9166 SEBASTIANI WAYTELEPHONE:
(916) 896-1974
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6CENSUS: 6DATE:
09/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Maria AgustinTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On September 10, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez met with Administrator (A1) Maria Agustin and explained the purpose of today's visit.

The Administrator holds current certificate #7001301740 and expires on March 19, 2027. The facility is licensed for 6 ambulatory clients. There are currently 6 residents who reside at this facility.

Upon arrival, the LPA observed that the facility has cameras in common areas including the living room and kitchen areas. At 9:10AM, LPA reviewed 6 out of 6 resident records and observed that consent for video surveillance forms were not on file for the residents.

At 9:15AM, LPA conducted records review of (5) staff and (6) resident files. Resident files contained required components including admission agreements, physician's reports, TB test records, and medical consent forms. The LPA observed that appraisals are conducted during the admission process and updated when there are changes in residents' care needs. LPA observed outdated Needs and Services Plans in the resident files for 2 to 3 years. Staff files contained the required components and were maintained current. The LPA observed updated training certificates were available for all staff.

At 10:00 AM, LPA Lopez toured the facility with A1. LPA Lopez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, facility bathrooms, laundry room, living room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.
Continued...
Arielle Pascua
Sulma Lopez
DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AGUSTIN CARE HOME
FACILITY NUMBER: 347000395
VISIT DATE: 09/10/2026
NARRATIVE
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LPA toured the kitchen which contained equipment for food preparation. The facility contained a food pantry in the kitchen and a refrigerator. LPA observed overflow foods were available in the garage where LPA observed 2 additional fridges and additional non-perishable food items. The facility contained at least 2- days' worth of perishable food items, and at least 7 days' of non-perishable food items. The kitchen refrigerator was observed to be in unsanitary condition and visibly stained with food residue. The LPA also observed grease and dust particles accumulated on the kitchen walls and cabinets. The LPA observed that medications, sharps, and toxins were securely stored in locked kitchen cabinets. The fire extinguisher was serviced annually on October 20, 2025.

The facility contained two living room areas for resident use. The living rooms contained enough seating to accommodate the current census. The dining area contained chairs for all residents and was observed to be clean and free of hazards.

LPA and A1 toured the facility bathrooms. LPA observed hand washing supplies were available in the facility including soap and paper towels. LPA also observed common towels being utilized. A1 stated they will remove the common towels and supply paper towels going forward. The facility bath tubs were observed to be unclean and in unsanitary condition. A1 stated that bath tubs are cleaned twice a week. A review of the second bathroom revealed that the bath tub was also in an unsanitary condition. The tub surfaces contained visible grime and residue from inconsistent or inadequate cleaning. A1 stated that the tubs appeared that way because they had just put cleaning supplies on the tubs such as baking soda, and will be cleaned later today.

LPA and A1 toured the resident bedrooms. The rooms were observed to be clean and free of odors. Resident beds furnished with clean bedding. The rooms contained beds, dressers, night stands, and closets for resident use. The furniture was observed to be in good repair. Each resident bedroom contained adequate lighting, windows in good repair, and smoke detectors in working order.

LPA and A1 toured the exterior of the facility. There is a body of water which is kept secured and inaccessible to residents in the front of the facility. A1 stated that it is a Koi Pond. The side exit was observed to be free of obstructions and the gate was in good working condition. The LPA observed that the facility perimeter fence was in good repair. The backyard contained a shaded area with patio furniture available for resident use. Continued...
NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AGUSTIN CARE HOME
FACILITY NUMBER: 347000395
VISIT DATE: 09/10/2026
NARRATIVE
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The LPA obtained the following documentation from the facility:

- LIC 308 Designation of Facility Representative
- LIC 500 Personnel Report
- LIC 610E Emergency and Disaster Preparedness Plan
- Updated Liability Insurance Certificate

As a result of this annual inspection, deficiencies were cited on the LIC 809-D. An exit interview was conducted and a copy of this report and Appeal Rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2026 12:43 PM - It Cannot Be Edited


Created By: Sulma Lopez On 09/10/2026 at 11:26 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AGUSTIN CARE HOME
FACILITY NUMBER: 347000395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2026
Section Cited
CCR
87468.2(a)(1)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a)...residents... shall have all of the following personal rights: (1) To have a reasonable level of personal privacy...
This requirement is not met as evidenced by:
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The Licensee will turn off the cameras immediately. Licensee aggreed to submit signed resident consent forms for camera use. Licensee agreed to update the Plan of Operation and submit a waiver request for video surveillance in the facility by 9/30/26 by 5:00PM.
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Based on observation, interviews, and record reviews, the Licensee did not ensure that residents provided documented consent for surveilance cameras in the kitched and living room common areas which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
09/30/2026
Section Cited
CCR87463(a)

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87463 Reappraisals- (a) Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months... to note significant changes in condition... and to keep the appraisal accurate. This requirement was not met as evidenced by:
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Licensee agreed to conduct resident reappraisals for the outdated records and submit copies to the LPA by 10/10/26 by 5:00PM.
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Based on observation, interviews, and record reviews, the Licensee did not ensure that resident reappraisals were maintained current and accurate by not completing reappraisals yearly which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Sulma Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2026 12:43 PM - It Cannot Be Edited


Created By: Sulma Lopez On 09/10/2026 at 11:46 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AGUSTIN CARE HOME
FACILITY NUMBER: 347000395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87303(a)(1)

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87303 Maintenance and Operation- (a) The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by:
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The Licensee stated that tubs will be cleaned today. Licensee agreed to develop a cleaning schedule for kitchen and bathrooms areas to be cleaned regularly and agreed to send a copy to the LPA by 9/30/26 by 5:00PM.
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Based on observation, interviews, and record reviews, the Licensee did not ensure that the facility bath tubs, refrigerators, cabinets, and walls were clean, sanitary, free of dirt, grease, grime, and residue which poses a potential Health, Safety, or Personal Rights to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Sulma Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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