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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
585002671
Report Date:
05/16/2024
Date Signed:
05/16/2024 03:50:17 PM
Document Has Been Signed on
05/16/2024 03:50 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:
M & L CARE HOME
FACILITY NUMBER:
585002671
ADMINISTRATOR/
DIRECTOR:
AGATI, MAXIM LORENZE R
FACILITY TYPE:
735
ADDRESS:
5656 MEADOW BROOKWAY
TELEPHONE:
(858) 371-8830
CITY:
MARYSVILLE
STATE:
CA
ZIP CODE:
95901
CAPACITY:
4
CENSUS:
4
DATE:
05/16/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:
Clifford Lelina and Ayson Aguirre
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Caregiver Clifford Lelina. Administrator Ayson Aguirre showed up during visit.
This facility has a fire clearance for three ambulatory and one non-ambulatory residents. The facility has four private resident rooms. There is one staff room that has a full private bathroom. There is one full common bathroom. There is an ample supply of perishable and nonperishable food.
Two resident files were reviewed and three staff files were reviewed.
The following shall be updated and submitted to Licensing by June 1 2024:
-LIC 500- facility personnel or staff schedule
-LIC 308- designation of administrative responsibility. (who is in charge when administrator is not present.)
No deficiencies cited during this visit.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/16/2024
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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