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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002772
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:14:16 PM

Document Has Been Signed on 01/22/2025 04:14 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:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Cindy Munoz Castlean and Benita Velenzuela LopezTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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LPAs Kerry Hiratsuka and Cassandra Mikkelson conducted this unannounced annual visit.

The main entrance opens to a hallway. To the left of the main entrance are two private resident rooms and one full common bathroom. To the right of the main entrance is a door leading to the garage. Towards the back of the facility is the main common area that has the kitchen, dining, and sitting area. To the right of of the main common area is a hallway leading to two private resident rooms that have their own full private bathrooms, and there is a laundry room. There are locked closets and cabinets for sharps, medications, files, and staff items.

Two resident files were reviewed.
Staff files were reviewed.

Multiple topics were discussed.

As a result of today's visit, no deficiencies were cited. Exit interview conducted with the Administrator. Copy of this report given to facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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