<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700927
Report Date: 02/02/2022
Date Signed: 02/02/2022 10:01:18 AM

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: 6DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Audrey Whittaker BriseeTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cassie Yang arrived unannounced on 2/2/2022 to conduct a required annual. LPA met with Audrey Whittaker Brisse, Caregiver, and explained purpose of inspection. LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive COVID-19 diagnoses. LPA were screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Caregiver contacted Leilani Aragon, Administrator, who informed LPA she cannot make it at this time. Administrator informed LPA that Caregiver, Audrey Whittaker Brisee, will be available to tour the facility with LPA. LPA observed (3) residents in the common area and (3) residents in their private rooms. The facility has an approved mitigation plan.

LPA and Caregiver toured the interior of the facility, including (4) private resident rooms, (2) common restrooms, kitchen, laundry, garage, and common areas. LPA observed it to be clean and in good repair. LPA observed required postings throughout in the facility. Inside temperature was observed to be 67* F. Fire extinguisher last serviced 11/15/2021. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed paper towels, soap, sanitizer and hand washing posters in the restrooms. LPA advised Caregiver to have trash can with lid in common restrooms. LPA observed ample PPE and medication supply located in secured areas. Sharps, Toxins and medications were secured. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Caregiver discussed vaccination status of residents and staff as well as visitation protocols per PIN 22--04. LPA reviewed records of Administrator Certificate and Certificate of Liability Insurance. Facility records were found to be current. LPA and Caregiver completed the infection control domain together and facility was found to be in compliance at this time.

LPA requested an updated copy of LIC 308 by 2/4/2022.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1