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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804103
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:35:07 PM

Document Has Been Signed on 04/16/2024 02:35 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AGAPE PAJARILLO CARE HOMEFACILITY NUMBER:
486804103
ADMINISTRATOR/
DIRECTOR:		PAJARILLO EPHRAIMFACILITY TYPE:
740
ADDRESS:841 ROLEEN DRIVETELEPHONE:
(707) 645-8463
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Anabel TuasonTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Caregiver Anabel Tuason.

This facility has a fire clearance for four non-ambulatory and two bedridden residents. There are four private rooms and one shared room. The shared room has a full private bathroom. There is a caregiver room. There are a couple of common areas and the kitchen and dining room. There is an ample supply of perishable and nonperishable food. LPA reviewed staff and resident records.

The following was observed during today's visit.
-Staff don't have training records. Per Title 22 regulations Personnel Records 87412(c) (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

A couple of topics were discussed.

Licensing fees are due by April 19, 2024.

The following shall be updated and submitted to Community Care Licensing Division by May 1, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal rights were provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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 04/16/2024 02:35 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 04/16/2024 at 02:03 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: AGAPE PAJARILLO CARE HOME
FACILITY NUMBER: 486804103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff records reviewed and there were no staff training logs, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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By 05/16/2024, the licensee shall submit a written statement stating how they shall ensure there is staff training records and how they shall ensure there is staff training annually.
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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
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