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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700927
Report Date: 02/09/2022
Date Signed: 02/09/2022 01:18:11 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: 6DATE:
02/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Audrey Whittaker BrisseTIME COMPLETED:
01:20 PM
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On 2/9/2022 at 12:10 pm, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced and spoke with Caregiver, Audrey Whittaker Brisse. Caregiver contacted Administrator, Leilani Aragon, who informed LPA that she just left the facility. LPA Yang observed Caregiver to be on the LIC 308. 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.

LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA was screened by Caregiver, upon entering the facility.

The purpose of this inspection was to conduct a records review.

Caregiver was unable to locate a copy of the staff roster and staff schedule. Caregiver contacted Administrator who informed LPA there is no physical copy in the personnel file. Administrator stated she will email one as soon as possible to LPA once completed.

LPA requested for Administrator to send a copy of staff roster and the weekly staff schedule by end of the week, 2/11/2022.

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



LPA Yang reviewed this report with Caregiver and provided a copy.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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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