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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804103
Report Date: 07/02/2024
Date Signed: 07/02/2024 08:25:28 PM

Document Has Been Signed on 07/02/2024 08:25 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/
DIRECTOR:		PAJARILLO EPHRAIMFACILITY TYPE:
740
ADDRESS:841 ROLEEN DRIVETELEPHONE:
(707) 645-8463
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
07/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:02 PM
MET WITH:Anne Tuason, Care staffTIME VISIT/
INSPECTION COMPLETED:
04:48 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with care staff, Anne Tuason. During a complaint investigation LPA discovered facility had no staff with proof of current CPR training. Staff S1 who was the only one present during LPAs arrival had proof of First Aid that expires 8/23/2024, but no CPR.





The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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 07/02/2024 08:25 PM - It Cannot Be Edited


Created By: Araceli Canela On 07/02/2024 at 04:07 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: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2024
Section Cited
CCR
1569.618(c)(3)

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H&S 1569.618(c)(3) Administration and management of residential care facilities; substituted qualifications; employee scheduling- (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:
(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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Facility to send in written plan on how they will make sure they have at least 1 staff with proof of CPR training.
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This requirement was not met as evidenced by: The facility failed have a staff present in the facility who has CPR training. This is a potential risk to the health & safety of residents in care.
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 Plan of correction due by 7/28/2024 attention LPA A Canela
HSC

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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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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