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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001511
Report Date: 10/21/2021
Date Signed: 10/21/2021 04:12:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AUGUSTIN GARDENSFACILITY NUMBER:
306001511
ADMINISTRATOR:FISK, RYAN & TYANAFACILITY TYPE:
740
ADDRESS:24361 AUGUSTINTELEPHONE:
(949) 916-3552
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
10/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Administrator Tyana Fisk TIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. Via phone LPA made consultation with Administrator Tyana Fisk. LPA stated the purpose of this visit.

On October 7, 2021, Community Care Licensing Division (CCLD) Orange Office received a letter from Administrator Tyana Fisk requesting for an increase in hospice waiver. LPA Marin reviewed the request and the compliance history of the facility. On October 14, 2021, Licensing Program Manager Luz Adams approved the request.

For this visit, LPA discussed with AD T. Fisk the terms and conditions of the hospice waiver. LPA then toured the interior of the facility and observed five residents in care and two staff members on the floor.

LPA Marin conducted an exit interview with AD T. Fisk. AD granted permission for staff to sign and receive the report. LPA left copies of this report, updated license and letter of approved hospice waiver in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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