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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002583
Report Date: 04/08/2022
Date Signed: 04/08/2022 10:28:13 AM

Document Has Been Signed on 04/08/2022 10:28 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:AGATI HOME CAREFACILITY NUMBER:
585002583
ADMINISTRATOR:AGATI, AZUCENAFACILITY TYPE:
735
ADDRESS:5554 MEADOW BROOK WAYTELEPHONE:
(530) 741-1434
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Concepcion Targa, StaffTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain on today's date. LPA met with Concepcion Targa, Staff.. LPA explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Gown, Gloves and N95. In addition, Staff screened LPA prior to entering the facility.

During the inspection, 2 clients were present at the facility and 2 were out of the facility. LPA toured facility with staff to ensure health and safety of clients in care. Areas toured include but are not limited to: common area, office area, 4 client bedroom, 1 private client bathroom, 1 shared bathroom, staff bedroom, laundry room, garage, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and staff completed the infection control domain and facility was found to be in substantial compliance at this time.

Facility has 30 days supplies of PPE available at the facility. LPA reviewed 2 of 2 clients Centrally Stored Medications. All medications had a physician's order on file and were all logged on Centrally Stored Medication Logs. LPA reviewed 2 of 2 clients P&I Money. P&I were locked and not kept with facility money. Facility has 7 days of non-perishable and 2 days of perishable food supply on today's date to meet the dietary needs of 3 clients in care.

During the inspection, LPA and facility staff discussed the facility's infection control and mitigation plan.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of this report was left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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