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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002772
Report Date: 10/02/2024
Date Signed: 10/02/2024 12:32:24 PM

Document Has Been Signed on 10/02/2024 12:32 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:AAVON CARE HOME 2FACILITY NUMBER:
585002772
ADMINISTRATOR/
DIRECTOR:		ROMULO AGUSTINOFACILITY TYPE:
735
ADDRESS:5555 HARCREST DR.TELEPHONE:
(530) 701-4037
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
10/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Benita Valenzuela LopezTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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LPA Hiratsuka conducted this unannounced case management visit in response to Alta California Regional Center (ACRC) inspection on August 22, 2024.

ACRC issued a Facility Action Report (FAR) regarding two medication issues. Today LPA interviewed Manager Benita Valenzuela Lopez, Caregiver Cindy Munoz, and Administrator Romulo Agustino. Licensee Jagdeep Bal showed up during visit.

The first medication issue ACRC had was a bubble pack that had one medication with a start date written on the bubble pack. According to ACRC the start date did not match the amount of pills in the bubble pack. There was one extra pill in the bubble pack. ACRC did their inspection in the morning time. The Medication Administration Record (MARS) shows the medication was given in the AM, but that is not necessarily what the prescription stated to give it. ACRC did not do a follow-up with the resident in question to ask if the resident was given the medication later in the day, nor did anyone from ACRC ask the resident what their preferences were for taking the medication Today, LPA reviewed the centrally stored medication record for the month of August, the actual prescription from the doctor, and the current bubble pack. The prescription states to give once daily and does not specify what time to give it. LPA gave suggestions to discuss with the doctor about the best times to give the medication to the resident and ask for time frames for the resident to take the medication without an repercussions.
The second medication issue ACRC had involved one medication that was stored in two bubble packs. One bubble pack was for AM and one was for PM. According to ACRC, the start dates do not match. One bubble pack was started the day after the other bubble pack. ACRC does not mention on the report that any medication dosages were missed. There are several different reasons why the two start dates do not match with the resident not missing any dosages. There are no missed dosages noted.

Based on LPA's observation LPA is unable to issue any deficiencies.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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