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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804103
Report Date: 10/04/2024
Date Signed: 10/30/2024 11:32:39 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2024 and conducted by Evaluator Araceli Canela
COMPLAINT CONTROL NUMBER: 21-AS-20240625100810
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: 6DATE:
10/04/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Anne Tuason, Lead care staffTIME COMPLETED:
03:59 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents Level of care not met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of gathering more information and delivering findings, regarding the above listed allegation. LPA met with Care staff, Anne Tuason and once again toured the home, made observations and took statements.

It was alleged residents level of care is not met, and that R1 is not being assisted; remains in bed and not getting to medical appoitnments. LPA observed R1 active in the facility on both occasions, making phone calls and setting up medical appointments. R1 stated their POA sets some appointments but R1 is also capable of doing them. If they need assistance from staff, they receive it. Staff disclosed R1 likes to set up their own appointments, but staff will assist if they ever need help. R1 has a coming up eye appoitnment in which facility staff will take R1 to the appointment. Facility staff or R1's POA take turns assiting R1 to medical appoitnmets.
Although the allegation may be true, based on the above information, and records reviewed, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, it is UNSUBSTANTIATED at this time. No citation issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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