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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002583
Report Date: 05/15/2023
Date Signed: 05/15/2023 12:51:20 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/15/2023 12:51 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:
05/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Azucena AgatiTIME COMPLETED:
01:00 PM
NARRATIVE
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05/15/2023 2:46 PM Licensing Program Analysts (LPA) Sarah Benson and Licensing Program Manager Lauren Crocker (LPM) arrived at the facility unannounced to conduct a Required Year inspection. Sarah Benson and Lauren Crocker met with administrator Azucena Agati (Administrator cert.6018548735 # exp 8-20-24 and Emielynn Galvan Care Staff) and explained the purpose of the visit.

Licensing representatives and the administrator and Care Staff toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven day non-perishable and (2) day perishable supply of food. Medication is locked in a cabinet.

Administrator certificate is current. All employees requiring background checks are cleared. All required postings are displayed within facility. No firearms are on premises. Smoke detectors are all operational. Fire extinguishers are fully charged and were inspected in August 2023 MD report identifies one resident as bedridden, fire clearance for one nonambatory in 2023. Last disaster drill was conducted in April 2023. In addition the facility conducts monthly fire drills. In the areas toured no immediate health, safety, or personal rights violations were observed.

Deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator .
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/15/2023 12:51 PM - It Cannot Be Edited


Created By: Sarah Benson On 05/15/2023 at 12:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: AGATI HOME CARE
FACILITY NUMBER: 585002583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2023
Section Cited
CCR
80087(g)

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Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Pinesol found unlocked under the sink in the residents restroom. Removed during visit.
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Licensee shall ensure that all toxins are retained inaccessible to the residents in care at all times when not in use.
**Cleared during visit**
Type A
05/16/2023
Section Cited
CCR
80020(a)

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All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
Facility has one resident that is noted to be bedridden on the MD report and the fire clearance allows for only 1 non-ambulatory.
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Licensee shall obtain either a MD report that reflects the resident is non-ambulatory, or will obtain a fire clearance for a bedridden resident, or will have the bedridden resident relocated.
Type B
05/29/2023
Section Cited
CCR85087(a)(4)

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No client bedroom shall be used as a public or general passageway to another room, bath or toilet.
LPA and LPM was informed that the staff utilize the bathroom and the shower in the master bedroom that is occupied by a resident.
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The licensee shall identify a different bathroom for staff to utilize and update the facility policies and procedures along with training staff to no longer utilize the master bathroom as a staff bathroom. Staff shall not use a residents bedroom as a passageway to a toilet, tub, or shower.
Type B
05/29/2023
Section Cited
CCR
85088(c)(4)(B)

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Furniture, Fixtures, Equipment and Supplies: top and bottom bed sheets; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and washcloths. The use of common towels and washcloths shall be prohibited. Missing paper towels in bathroom and bedding on bed
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The licensee shall ensure that all the residents beds are equip with the required bedding identified in 85088(c) and shall ensure that there are paper towels available for residents when using the restroom (or towels that are not shared). Send proof of correction to Licensing by 5/29/23
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
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