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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700927
Report Date: 02/11/2021
Date Signed: 02/11/2021 04:45:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AUGUSTUS ELDER CARE HOME, LLCFACILITY NUMBER:
342700927
ADMINISTRATOR:ARAGON, LEILANIFACILITY TYPE:
740
ADDRESS:5105 SCHUYLER DRTELEPHONE:
(925) 922-4561
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
02/11/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Leilani Aragon, AdminsitratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Melana Llopis contacted the facility Administrator, Leilani Aragon on 02/11/2021 for a scheduled Pre-Licensing Tele-Visit Inspection. LPA met with Administrator via TEAMS due to Covid-19 and pre-cautionary measures. The facility currently has a fire clearance for six (6) non-ambulatory residents. LPA Llopis observed five (5) non-ambulatory residents in care during the virtual visit.

LPA and Administrator toured the facility together via TEAMS. Areas inspected include but are not limited to the following: four (4) resident bedrooms, two (2) resident bathrooms, one (1) staff room, linen closet, living room, kitchen, laundry room, garage and backyard. LPA observed the facility to be in good repair and each resident room to have sufficient lighting and the required furniture. LPA had the Administrator measure their water temperature and was measured at 108 degrees F. LPA observed the bathrooms to have required grab bars and non-skid mats. LPA found sharps, cleaning chemicals, and medications to be locked and inaccessible to residents in care. The fire extinguisher was found to be fully charged and last serviced on 11/05/2020. The carbon monoxide device and smoke detectors were found to be in working order. LPA observed the facility to have an adequate supply of 2 day nonperishable food items and a sufficient supply of 7 day nonperishable food items.

LPA reviewed one (1) resident file and one (1) staff file. Files were found to be current and complete.
Staff (S1) has background clearance and are first aid certified.

LPA presented COMP III powerpoint presentation to Administrator. The facility is now ready to be approved for license.

LPA will notify the Central Applications Bureau (CAB) of the facility's current status.

No deficiencies were found during today's inspection.
Exit interview conducted with Administrator via TEAMS. Copy of report provided via email. Administrator to print, sign and send a signed copy to LPA Llopis and to keep a signed copy on file at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
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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