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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 10:28:45 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Concepcion Targa, StaffTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a case management visit on today's date. LPA met with Concepcion Targa, Staff.. LPA explained the purpose of the visit. Prior to initiating the case management visit. 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.

May 2021, Licensee informed LPA that Licensee will be making changes to the facility. Licensee submitted the appropriate building permits and floor plan to Licensing June 2021. Licensee informed LPA that the room was completed on March 2022. The facility requested for a new fire clearance on 03/11/2022 and was approved on 3/15/2022. The facility was requesting a fire clearance for room that was added to the facility as a staff room. Facility submitted in a new facility sketch that reflect the change.

During today's visit, LPA and staff toured the facility inside and out. LPA observed that the room is ready for occupancy and used as a STAFF ROOM as approved by the Fire Marshall.

No citations was observed during this visit. An exit interview was conducted and a copy of this report was left with Concepcion Targa, Staff, whose signature on this form confirms receipt.
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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