Agustin Care Home

Type of visit: Required - 1 Year

On September 10, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez met with Administrator (A1) Maria Agustin and explained the purpose of today's visit. The Administrator holds current certificate #7001301740 and expires on March 19, 2027. The facility is licensed for 6 ambulatory clients. There are currently 6 residents who reside at this facility. Upon arrival, the LPA observed that the facility has cameras in common areas including the living room and kitchen areas. At 9:10AM, LPA reviewed 6 out of 6 resident records and observed that consent for video surveillance forms were not on file for the residents. At 9:15AM, LPA conducted records review of (5) staff and (6) resident files. Resident files contained required components including admission agreements, physician's reports, TB test records, and medical consent forms. The LPA observed that appraisals are conducted during the admission process and updated when there are changes in residents' care needs. LPA observed outdated Needs and Services Plans in the resident files for 2 to 3 years. Staff files contained the required components and were maintained current. The LPA observed updated training certificates were available for all staff. At 10:00 AM, LPA Lopez toured the facility with A1. LPA Lopez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, facility bathrooms, laundry room, living room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Continued... LPA toured the kitchen which contained equipment for food preparation. The facility contained a food pantry in the kitchen and a refrigerator. LPA observed overflow foods were available in the garage where LPA observed 2 additional fridges and additional non-perishable food items. The facility contained at least 2- days' worth of perishable food items, and at least 7 days' of non-perishable food items. The kitchen refrigerator was observed to be in unsanitary condition and visibly stained with food residue. The LPA also observed grease and dust particles accumulated on the kitchen walls and cabinets. The LPA observed that medications, sharps, and toxins were securely stored in locked kitchen cabinets. The fire extinguisher was serviced annually on October 20, 2025. The facility contained two living room areas for resident use. The living rooms contained enough seating to accommodate the current census. The dining area contained chairs for all residents and was observed to be clean and free of hazards. LPA and A1 toured the facility bathrooms. LPA observed hand washing supplies were available in the facility including soap and paper towels. LPA also observed common towels being utilized. A1 stated they will remove the common towels and supply paper towels going forward. The facility bath tubs were observed to be unclean and in unsanitary condition. A1 stated that bath tubs are cleaned twice a week. A review of the second bathroom revealed that the bath tub was also in an unsanitary condition. The tub surfaces contained visible grime and residue from inconsistent or inadequate cleaning. A1 stated that the tubs appeared that way because they had just put cleaning supplies on the tubs such as baking soda, and will be cleaned later today. LPA and A1 toured the resident bedrooms. The rooms were observed to be clean and free of odors. Resident beds furnished with clean bedding. The rooms contained beds, dressers, night stands, and closets for resident use. The furniture was observed to be in good repair. Each resident bedroom contained adequate lighting, windows in good repair, and smoke detectors in working order. LPA and A1 toured the exterior of the facility. There is a body of water which is kept secured and inaccessible to residents in the front of the facility. A1 stated that it is a Koi Pond. The side exit was observed to be free of obstructions and the gate was in good working condition. The LPA observed that the facility perimeter fence was in good repair. The backyard contained a shaded area with patio furniture available for resident use. Continued... The LPA obtained the following documentation from the facility: - LIC 308 Designation of Facility Representative - LIC 500 Personnel Report - LIC 610E Emergency and Disaster Preparedness Plan - Updated Liability Insurance Certificate As a result of this annual inspection, deficiencies were cited on the LIC 809-D. An exit interview was conducted and a copy of this report and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Sep 30, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a)...residents... shall have all of the following personal rights: (1) To have a reasonable level of personal privacy... This requirement is not met as evidenced by: Based on observation, interviews, and record reviews, the Licensee did not ensure that residents provided documented consent for surveilance cameras in the kitched and living room common areas which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: The Licensee will turn off the cameras immediately. Licensee aggreed to submit signed resident consent forms for camera use. Licensee agreed to update the Plan of Operation and submit a waiver request for video surveillance in the facility by 9/30/26 by 5:00PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(a) · Plan of correction due date: Sep 30, 2026

87463 Reappraisals- (a) Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months... to note significant changes in condition... and to keep the appraisal accurate. This requirement was not met as evidenced by: Based on observation, interviews, and record reviews, the Licensee did not ensure that resident reappraisals were maintained current and accurate by not completing reappraisals yearly which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Licensee agreed to conduct resident reappraisals for the outdated records and submit copies to the LPA by 10/10/26 by 5:00PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Sep 30, 2026

87303 Maintenance and Operation- (a) The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: Based on observation, interviews, and record reviews, the Licensee did not ensure that the facility bath tubs, refrigerators, cabinets, and walls were clean, sanitary, free of dirt, grease, grime, and residue which poses a potential Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: The Licensee stated that tubs will be cleaned today. Licensee agreed to develop a cleaning schedule for kitchen and bathrooms areas to be cleaned regularly and agreed to send a copy to the LPA by 9/30/26 by 5:00PM.

Type of visit: Required - 1 Year

On 9/22/25, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a required - 1 Year inspection visit. LPA met with Administrator Maria Agustin (S1) and explained the purpose of the visit. An entrance interview was conducted. Administrator certification expires on 3/27 (7001301740). The facility is licensed to serve up to 6 ambulatory residents. Current census is 6. LPA toured the facility with S1. LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. The indoor air had a cigarette like odor, licensee stated four residents smoke in the patio area. LPA and licensee discussed installing HEPA air filters in the facility to assist with maintaining healthful indoor air quality. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 110*F which was within the required range of 105-120*F. The temperature inside the facility measured at 76*F which was within the required range of 68-85*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. The last fire drill was conducted 9/1/25. There are security cameras in public/common areas of the facility; No cameras are in private areas such as resident bedrooms and bathrooms. Continued on 809-C Exterior passageways were clean and clear of any obstructions. There is a covered patio area with table and chairs client and visitor use, furniture observed to be in good condition. Clients are supervised at all times when they are outside. There are two gates with a self-latching mechanism for persons to exit the backyard in emergencies. LPA observed two locked shed which contains general equipment and supplies. LPA requested resident and staff files for review. LPA reviewed (3) staff files and (6) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following forms and documents were obtained: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited. An exit interview was conducted, and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: Required - 1 Year

On 9/16/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a required - 1 Year inspection visit. LPA met with Administrator Maria Agustin and explained the purpose of the visit. Administrator certification expires on 3/19/2025. The facility is licensed to serve up to 6 ambulatory residents. Current census is 4. LPA toured the facility with Maria Agustin. LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 109.9*F which was within the required range of 105-120*F. The temperature inside the facility measured at 74*F which was within the required range of 68-85*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. LPA requested resident and staff files for review. LPA reviewed (2) staff files and (3) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following forms and documents were obtained: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed. An exit interview was conducted, and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Sep 16, 2024

Type of visit: Case Management - Other

On 12/29/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit regarding a receipt of a death report. LPA met with Administrator Maria Agustin and explained the purpose of the visit. The purpose of this case management visit is to follow up on a death report the Department received on 12/22/2023. LPA reviewed death report which revealed that resident 1 (R1) passed away on 12/18/23. R1’s reason for hospitalization and cause of death was not indicated on the death report. Based on interview conducted with Administrator, R1 refused meals and medication twice at approximately 4 pm and 7 pm on 12/3/23. On 12/4/23, when staff wake R1 up for breakfast at 6:50 am, R1 didn’t respond. Facility staff then called 9-1-1. It was learned that on 12/14/23 attending nurse told the administrator that R1 has an infection of the blood called sepsis and being treated with antibiotic and don’t know how R1 got it. Administrator stated that she is waiting for the R1’s medical records and will send LPA Truong a copy once she receives it. The following documents was obtained during today’s visit: Incident reports pertaining to R1, Physician’s Report, Identification and Emergency Information, and Appraisal/Needs and Service Plan. Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. The administrator was advised that LPA would return at a later date to complete the investigation. An exit interview was held, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 29, 2023

Allegation investigated: Staff did not refill resident's medication in a timely manner.

On 12/1/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to commence a complaint investigation with the allegation above. LPA met with Administrator Maria Agustin and explained the purpose of the visit. Through interview and review of records, LPA learned that resident (R1) did ran out of medication, Quetiapine, for 5 days. From review of documents and interview with staff, it appears that the facility did contact the resident's pharmacy for medication refill, however the pharmacy did not get a response from the primary doctor and the prescribing doctor from the hospital. R1’s medication, Quetiapine, ran out on 11/22/23 and facility sent resident to ER on 11/27/23. The administrator acknowledged that she has made a mistake and should have gone to ER to get the medication sooner instead of waiting on the pharmacy. Continued on 9099-C Substantiated Based on interviews conducted, and records reviewed, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed, copy of report given. As a result of the investigation, LPA finds the allegation above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Dec 1, 2023 · control 27-AS-20231128090036

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 4, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interview, the Licensee did not ensure that R1 is receiving medication in a timely manner. R1 missed 5 doses of one medication. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: The Administrator will devise a plan of correction to ensure that resident medications are re-ordered in a timely manner. Plan will be submitted to CCL by 12/4/2023.