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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585920007
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:06:26 PM

Document Has Been Signed on 07/11/2024 04:06 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 HOMECARE 3FACILITY NUMBER:
585920007
ADMINISTRATOR/
DIRECTOR:
AZUCENA AGATIFACILITY TYPE:
735
ADDRESS:5664 SEEDLING WAYTELEPHONE:
(530) 870-8805
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Azucena Agati and Mae KatzTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA met with Administrator Azucena Agati and Co-Administrator 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.

LPA reviewed staff training and reviewed two resident records. LPA also reviewed the medication administration records.

The following shall be updated and submitted to Community Care Licensing Division by August 10, 2024:
LIC 500 facility personnel or staff schedule
LIC 308 designation of administrative responsibility.


Several topics were discussed.

No deficiencies cited.
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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