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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002583
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:25:00 PM

Document Has Been Signed on 05/02/2024 03:25 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AGATI HOME CAREFACILITY NUMBER:
585002583
ADMINISTRATOR/
DIRECTOR:		AGATI, AZUCENAFACILITY TYPE:
735
ADDRESS:5554 MEADOW BROOK WAYTELEPHONE:
(530) 741-1434
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Mae KatzTIME VISIT/
INSPECTION COMPLETED:
03:34 PM
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LPA Hiratsuka conducted this unannounced annual visit.

This facility has a fire clearance for three ambulatory and one non-ambulatory residents. This facility has four private resident rooms and one staff room. The staff room has a full private bathroom. There is one full common bathroom. There is a common area, kitchen, and office area. There is a laundry room and a door that connects to the garage. The garage is used for storage. The facility has an ample supply of perishable and nonperishable food. There are locked cabinets for medications and cleaning toxins. The backyard is well maintained.

Four resident files were reviewed and staff training was reviewed.

Several topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 20, 2024:
-LIC 308 designation of administrative responsibility
-LIC 500 facility personnel or staff schedule

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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