365530355-2-9-2026-56-AS-LFAW-DR5SR6-20260209130550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530355
Report Date: 02/09/2026
Date Signed: 02/09/2026 01:05:56 PM

Document Has Been Signed on 02/09/2026 01:05 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	AGATE HOME CARE		FACILITY NUMBER:	365530355
ADMINISTRATOR/ DIRECTOR:	DELFIN, RAINIER		FACILITY TYPE:	740
ADDRESS:	7254 AGATE STREET		TELEPHONE:	(909) 919-3877
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91701
CAPACITY: 6		CENSUS: 0	DATE:	02/09/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Karen Bustillos, Licensee and Rainier Delfin, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) LaVette Farlow, arrived at Agate Home Care, to conduct an announced Pre-Licensing visit for licensure. LPA was greeted by Administrator Rainer Delfin, and Karen Bustillos, Licensee. LPA introduced self and stated purpose of the visit. LIC200 application was submitted on 02/07/2025 for six (6) bed capacity, (5) non-ambulatory, and (1) bedridden resident. Fire Safety Inspection clearance was granted for (5) non-ambulatory residents, and (1) bedridden resident on 07/21/2025. LPA toured the facility inside and outside and observed the following: Structure: Facility is a one story house with (4) resident bedrooms, (2) resident bathrooms, 1 office/staff area with a bathroom, extra room attached to the garage used as a storage space, living room, dining area, kitchen, pantry, backyard, and attached garage. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Two bedrooms accommodates two non-ambulatory residents in each room, and two bedrooms accommodates one non-ambulatory private which room number four (4) is for a bedridden resident. Bathrooms: The resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AGATE HOME CARE	FACILITY NUMBER: 365530355
	VISIT DATE: 02/09/2026

NARRATIVE

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Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent, and chemicals are stored in locked cabinets. There was a pantry stocked with non-perishable food and perishable food found in the refrigerator. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the bathroom and kitchen faucet measured at 93.9 and 94.3 degrees Fahrenheit. Administrator Rainier adjusted the water level and the water measure 122.3 and 124.2. LPA advised Administrator to monitor the water level and consider purchasing "caution hot water" signs to be posted. LPA observed a functional washer and dryer are located outside across from the garage in a closed room.

Living/Family room: There was a furnished living room with reading material and a TV observed.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies stored in a closet.

Yards/Outside: A self-latching handle gate on the left and right side of the house that leads into the backyard. There are no firearms, ammunition, swimming pool or bodies of water observed. LPA observed an additional room attached to the garage currently used as storage. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan: Facility sketch, visiting rules, and personal rights were observed posted by the entrance. LPA observed the Licensee has an operational phone line 909-204-2454, for residents in care.

General items: The smoke and carbon monoxide detectors were tested and are operable. There was a fully charged fire extinguishers observed. Resident/Staff records storage space for filing. First Aid kit with required components, and a locked area for medication storage was observed.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. LPA completed COMP III with the Licensee at the conclusion of the inspection.

Licensee will be notified once facility is licensed. An exit interview was conducted, and this report was discussed and provided to Administrator Rainier Delfin and Karen Bustillo, Licensee.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

LIC809 (FAS) - (06/04)

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