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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700927
Report Date: 01/26/2023
Date Signed: 01/31/2023 02:03:41 PM


Document Has Been Signed on 01/31/2023 02:03 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, 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:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Audrey Whittaker BrissettTIME COMPLETED:
05:45 PM
NARRATIVE
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On 1/26/23, LPA Mknelly returned to follow-up from 1/25/23 Annual inspection.
LPA followed the department's covid 19 procedures, wore a surgical mask and was screened by staff.
LPA informed caregiver of the reason for the visit.

On 1/25/23 violations were not cited due to technical malfunction;
On 1/25/23 LPA observed: Licensee has not insured that quarterly fire drills are completed and there is a resident with dementia in care. At today's inspection, caregiver presented a Fire Drill report for a 1/25/23 fire drill. However, caregivers were unaware of the drill conducted and Licensee and others stated as participating were not present.
The fire alarm in room 3 had a disabled fire alarm that has been removed and not replace. On 1/26/23, LPA observed the smoke alarm in place and operational.
Both constitute an immediate risk to resident.

LPA observed that issue that repairs had been done to damaged wall, a broken closet slider was removed and beds were rearranged to clear the sliding door fire exit.

As a result of this the visits on 1/25/23 and 1/26/23, he following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed with Audrey Whittaker Brissett. Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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 2


Document Has Been Signed on 01/31/2023 02:03 PM - It Cannot Be Edited

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: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2023
Section Cited

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Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met based on observation and statements of 1/25/23 that smoke detectors were inaoperable
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On 1/25/23 the last of the smoke detectors was replaced after several weeks of malfuntion. Neither CCL nor fire was notified.
Licensee will submit a plan for notification to CCL and Fire in the case of malfuntion of fire systems to CCL by the POC date of 1/30/23.
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and repairs were completed after the inspection on 1/25/23. This posed a danger to residents
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Type A
01/30/2023
Section Cited

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Care of Persons with Dementia (k) The following...requirements must be met ...:
(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement was not met based on
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The drill documented for 1/25/23 was found to be insufficient. Licensee will complete an actual drill that includes staff practice of emergency procedures by the POC date of 1/30/22. Proof of drill to be submitted to CCL.
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statements and record review that
drills had not been completed for greater that 9 months with a resident with demetia in care.
This posed an immediate risk to residents
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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: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2