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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804103
Report Date: 03/24/2025
Date Signed: 03/24/2025 12:55:30 PM

Document Has Been Signed on 03/24/2025 12:55 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:
03/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Anabel Tuason, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Anabel Tuason, Caregiver. Administrator was at a patient evaluation and was unable to attend, Anabel Tuason is designated to sign and receive this report. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for three (3), with one (1) Hospice resident currently in care and is approved for all non-ambulatory residents of which two (2) may be bedridden.

At approximately 10:05 AM, LPA initiated a tour of the facility with Caregiver and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 7/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 108.5 Degrees F in kitchen sink, 106.1 Degrees F in shared bathroom, and 105.2 Degrees F in master bathroom, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked.

LPA observed at least a 2-day supply of perishable and 7-day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered, as well as an emergency water supply. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed three locked sheds in the backyard which LPA inspected and observed the content to be decorations, winter coats belonging to staff, gardening supplies, and emergency supplies. Facility telephone was tested and operational during inspection.

Continued 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AGAPE PAJARILLO CARE HOME
FACILITY NUMBER: 486804103
VISIT DATE: 03/24/2025
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Continued from 809...

At approximately 11:10 AM LPA conducted review of four (4) staff records. All required documentation present.

At approximately 11:40 AM LPA conducted a review of four (4) resident records. Three (3) of four (4) residents records did not contain an LIC 625 - Appraisal Needs and Service Plan. Deficiency Cited.

At approximately 12:30 PM LPA and Caregiver conducted a spot check of medication and medication records. Medication is centrally stored and locked.

LPA observed that Administrator submitted a re-certification request on 2/1/2025.



LPA and Caregiver discussed facility's Infection Control Plan and Emergency Disaster plan, last updated 1/2025. Facility’s last quarterly disaster drill was conducted on 02/15/2025.

The following updated documentation was received during this visit:

Liability Insurance
LIC500- Personnel Report
LIC308- Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with Caregiver and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2025 12:55 PM - It Cannot Be Edited


Created By: Elias Magdaleno On 03/24/2025 at 12:34 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: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

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 three out of four residents did not have an Appraisal Needs and Service Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Licensee to submit self-certification that all residents in care have recieved a current and accurate Appraisal Needs and Serice Plan. Licensee shall also ensure future residents recieve a pre-appraisal before moving into facility.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


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