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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000846
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:07:59 AM

Document Has Been Signed on 06/06/2023 11:07 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ROLANDO & MARYBEL AGDIGOS CARE HOMEFACILITY NUMBER:
347000846
ADMINISTRATOR:AGDIGOS, MARYBELFACILITY TYPE:
735
ADDRESS:2352 MATSON DRIVETELEPHONE:
(916) 424-3256
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 4DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marybel AgdigosTIME COMPLETED:
11:30 AM
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On 6/5/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Assistant Administrator Mary Cres Agdigos and explained the purpose of today’s visit. Administrator Marybel Agdigos arrived a bit later. Administrator holds current certificate # 6007523735 and expires on 12/4/2023. The facility is licensed for 6 ambulatory clients. There are currently 4 clients who reside at this facility. Mary Cres 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 111.7 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 72 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.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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: ROLANDO & MARYBEL AGDIGOS CARE HOME
FACILITY NUMBER: 347000846
VISIT DATE: 06/06/2023
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LPA requested client and staff files for review. LPA reviewed (4) client files and (4) staff files, including criminal record clearances. LPA reviewed staff associations to the facility. A full Care Tool Inspection was completed at facility.

The following documents was obtained during today's visit:
Administrator Certificate, Designation of Administrative Responsibility, Personnel Report, Emergency Disaster Plan 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: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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