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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585920007
Report Date: 07/28/2023
Date Signed: 07/28/2023 11:56:52 AM

Document Has Been Signed on 07/28/2023 11:56 AM - 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 HOMECARE 3FACILITY NUMBER:
585920007
ADMINISTRATOR:TARGA, CONCEPCIONFACILITY TYPE:
735
ADDRESS:5664 SEEDLING WAYTELEPHONE:
(530) 870-8805
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 0DATE:
07/28/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Azucena Agati and Mae KatzTIME COMPLETED:
12:05 PM
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LPA Hiratsuka conducted this announced prelicensing visit. LPA met with Applicant Azucena Agati and Facility Representative Mae Katz.

This facility has a fire clearance for three ambulatory and one non-ambulatory residents. This facility has four private resident rooms and no staff room. The facility is required to have 24 hour awake staff. The main entrance opens to a hallway. There are two private resident rooms and a full common bathroom to the left of the main entrance. On the right there is a door leading to the garage. On the right of the facility has a second hallway that has two private resident rooms and both have full private bathrooms. One room has a door to the outside. The back of the facility is where the kitchen, dining, and sitting areas are located. There is a sliding door to the outside. The gate is located on the same side as the garage. On the side opposite the garage there is a shed.

Component III orientation was waived because Applicant owns other facilities.

This facility meets regulations. LPA is going to submit this report to the application specialist.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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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