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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002583
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:04:47 PM

Document Has Been Signed on 07/11/2024 04:04 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:
07/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Administrator Azucena Agati and Assistant Administrator Mae KatzTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kerry Hiratsuka conducted this visit in response to Alta California Regional Center's Title 17 inspection done on June 20, 2024. LPA conducted this visit at Agati Home Care 3 #585920007, with permission from Licensee/Administrator Azucena Agati.

On June 20, 2024, Alta California Regional Center inspected the medication administration records (MARS). The regional center found the medication destruction record was not completed. The Administrator stated she takes the medications that have been discontinued or expired to the pharmacy and that she forgot log it in. As a result, Alta California Regional Center issued a Facility Action Report (FAR) because the Administrator forgot to log in the destroyed medications. This is also a violation of Title 22 regulations.

Alta California Regional Center issued a FAR against the facility because they stated one resident didn't get their medication. LPA interviewed Co-Administrator and Co-Administrator stated the resident did get their medication, but while at an outing for breakfast. The caregiver did not sign the MARS because they took the pill with them but didn't want to sign the MARS that the medication was given until the resident took the medication. Alta California Regional Center didn't contact the resident in question to ask if they received their medication. LPA offered suggestions on how to document when a resident's medication does not specify an actual set time (example, medication is prescribed by doctor to be taken at 8:00am every day. Instead it states takes one in the morning and one at night). Title 22 regulations does not require MARs except for "as needed" medications.

Alta California Regional Center issued a FAR against the facility for staff not having continuing education training in 2020. Title 22 Regulations does not require continuing education for staff. Title 22 regulations require knowledge and training for staff, but does not specify how many hours nor does it state required annual training.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AGATI HOME CARE
FACILITY NUMBER: 585002583
VISIT DATE: 07/11/2024
NARRATIVE
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Today, LPA is issuing a citation because of the medication destruction log was not being completed. Licensee/Administrator already submitted a written plan of correction stating the staff were given refresher training on record keeping for medication.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights were provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2024 04:04 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 07/11/2024 at 03:41 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AGATI HOME CARE
FACILITY NUMBER: 585002583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2024
Section Cited
CCR
80075(l)

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Health Related Services. Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client.
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Corrected during visit. Licensee already submitted a written plan of correction on medication destruction log.
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Licensee failed this because Co-Administrator and Administrator forgot to log medications that were destroyed. This poses a potential risk health and safety risk to residents.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
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