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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002583
Report Date: 06/07/2023
Date Signed: 06/07/2023 05:06:48 PM

Document Has Been Signed on 06/07/2023 05:06 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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:
06/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Azucena AgatiTIME COMPLETED:
05:00 PM
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06-07-23 Sarah Benson arrived unannounced for Case Management Deficiencies and meet with Azucena Agati.
On 05-15-23 during Annual inspection the following sections were cited.
CCR 80087(g) Cleaning solutions were not locked up. The cleaning solutions were locked up during annual visit.
CCR 80020(a) Resident was listed as bedridden. Dr. note was presented for patient as non-ambulatory on 05-16-2023.
CCR 85087(a)(4) Client bedroom was used as public passageway to restroom. Rooms were traded with staff and client has privacy.
CCR 85088(c)(4)(B) No mattress pads were provided on clients beds. On 06-07-23 clients beds have mattress pads.

NO DEFICIENCIES AT THIS TIME.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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