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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001511
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:30:31 PM


Document Has Been Signed on 06/06/2022 03:30 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, 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: 6DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator Tyana Fisk TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Tyana Fisk; and stated the purpose of this visit.

This facility is a single level and licensed for 6 non-ambulatory with hospice waiver for four. For this visit there were three residents under hospice care.

LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA toured the interior and exterior portions of the facility. There were six resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide were tested to be operational. Paging system was observed to be functional. Bathrooms were provided with handrails and nonskid floor mats. Hot water was measured at 110 degrees Fahrenheit. Medications and cleaning supplies were inaccessible to residents in care. LPA observed personal protective equipment in place. Fire extinguisher was charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit door was self closing and self latching. LPA Marin reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that an support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA discussed California Code of Regulations Sections (CCR) 87633 Hospice Care for Terminal Ill Residents and 87606 Care of Bedridden Residents. AD will submit a copy of the updated floor plan to Community Care Division before June 20, 2022. AD will send incident reports to CCLASCPOrangeCountyRO@dss.ca.gov

No citation was issued was issued on this visit.

LPA Marin conducted a phone exit interview with AD Tyana Fisk. AD gave permission for staff to sign and receive this report. Copies of this report, advisory notes and CCR discussed left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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