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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 121373153
Report Date: 05/13/2024
Date Signed: 05/13/2024 01:49:58 PM

Document Has Been Signed on 05/13/2024 01:49 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AGUILAR MANORFACILITY NUMBER:
121373153
ADMINISTRATOR/
DIRECTOR:
AGUILAR, STIIVIFACILITY TYPE:
740
ADDRESS:6433 EGGERT ROADTELEPHONE:
(707) 443-5160
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 15CENSUS: 11DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Stiivi AguilarTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Stiivi Aguilar and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. LPA observed several food items in the facility pantry that were past expiration dates. In the remaining area's toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. First Aid/CPR certification was current. Medications were also reviewed.

The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. The last disaster drill was conducted and documented on 4-5-24, the facility has been conducting drills every month.


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Stiivi Aguilar and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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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Document Has Been Signed on 05/13/2024 01:49 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 05/13/2024 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGUILAR MANOR

FACILITY NUMBER: 121373153

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed several food items past the expiration date in the facility pantry, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Licensee immediately removed all expired items. POC Cleared at time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


LIC809 (FAS) - (06/04)
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