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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804103
Report Date: 04/04/2023
Date Signed: 04/04/2023 03:05:01 PM

Document Has Been Signed on 04/04/2023 03:05 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AGAPE PAJARILLO CARE HOMEFACILITY NUMBER:
486804103
ADMINISTRATOR:PAJARILLO EPHRAIMFACILITY TYPE:
740
ADDRESS:841 ROLEEN DRIVETELEPHONE:
(707) 645-8463
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 4DATE:
04/04/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ephraim Parajillo, Licensee ApplicantTIME COMPLETED:
03:20 PM
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On 4/4/2023 Licensing Program Analyst (LPA) Tobola conducted a pre-licensing inspection and was greeted by Licensee Applicant, Ephram Parajillo and current Licensee, Alma Guba. This pre-licensing inspection is being conducted due to a change of ownership. Fire Clearance has been approved for 6 residents; 4 non-ambulatory and 2 bedridden with a special condition that only one bedridden client shall be housed at one time. There are currently 4 residents in care some of which with a diagnosis of dementia and none of which are on hospice. Licensee is in the process of re-admitting residents to the new facility ownership.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. Fire extinguisher was recently service and charged on 3/27/2023. Smoke detectors and carbon monoxide detectors were tested and found to be operating. Emergency exits along the both sides of the facility have appropriate hardware and found to be unobstructed. Auditory alarms at all exits were in working order. Water measured between 109.4 & 116.6 degrees F in faucets used by residents which falls within regulation between 105 & 120 degrees F.

There was an ample supply of linens, dishes and cooking supplies for resident use. In addition, there was a sufficient supply of cleaning supplies and hygiene products available for residents upon request. LPA observed adequate supply of both perishable and non-perishable food sufficient for the 4 residents in care. Toxins were observed to be secured in cabinets located in the staff quarters, under bathroom sicks and in outside shed area. Knives and other sharp items were also secured in a designated drawer in the kitchen. Medications are centrally stored in a locked cabinet in the staff quarters along with resident, staff and medication records all found to be secured.

Licensee will be sending a copy of the updated liability insurance to CCLD. Component III orientation was conducted with the Licensee Applicant. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided to the Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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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