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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700927
Report Date: 08/05/2021
Date Signed: 08/06/2021 12:29:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 4DATE:
08/05/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Adminsitrator, Glenn BlogTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 08/05/2021 to conduct a Required 1 - year annual inspection. Prior to visit LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Denise Hall, staff, upon entering the facility. Staff, Audrey Whittaker contacted Administrator and made him aware of LPA's presence and purpose of the visit. Administrator appointed staff (S2) to tour with LPA due to their absence.

LPA toured the facility with S2, areas inspected include but are not limited to the following: facility living room, dining room, kitchen, backyard, garage, laundry room, resident bedrooms and bathrooms. LPA observed the facility to be clean, odor free and in good repair. LPA observed knives, cleaning supplies and medications locked and inaccessible to residents in care. LPA observed a sufficient supply of 7 day nonperishable food items and 2 day perishable food items. LPA observed an adequate supply of PPE. LPA found the fire extinguisher to be last serviced on 1/1/2021 and fully charged. LPA found resident bedrooms to have required furniture and sufficient lighting. LPA found the bathrooms to have required grab bars and nonskid shower surface. LPA measured the water temperature to be 105.5 degrees F. S2 tested the smoke detectors and carbon monoxide device and LPA observed both to be in working order. First aid kit was found to be complete.
LPA observed one (1) resident in care to be using oxygen but did not find an "oxygen in use" sign posted.
LPA reviewed a sample of one (1) resident record and was found to be current and complete. LPA reviewed two (2) hospice care plans for two (2) residents in care receiving hospice services. Hospice care plans were found to be sufficient.
LPA reviewed two (2) staff files and found staff files to be current and complete.
LPA conducted a medication audit for one (1) resident and found no errors.

As a result of today's visit, a deficiency is being cited and can be found on LIC 809-D, per California code of regulations, title 22.
Exit interview conducted, copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AUGUSTUS ELDER CARE HOME, LLC
FACILITY NUMBER: 342700927
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)

87618 Oxygen Administration - Gas and Liquid
(b) In addition to Section 87611(b), the licensee shall be responsible for the following:
(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2021
Plan of Correction
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Licensee agrees to post the required "No-Smoking-Oygen in Use" sign in the facility by POC date provided.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
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