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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201900
Report Date: 04/08/2024
Date Signed: 04/08/2024 03:19:03 PM


Document Has Been Signed on 04/08/2024 03:19 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:AUGDON SENIOR CARE HOMEFACILITY NUMBER:
547201900
ADMINISTRATOR:RENEE ARREGUIN (AGUILAR)FACILITY TYPE:
740
ADDRESS:2610 S. DOLLNER STREETTELEPHONE:
(559) 303-8783
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:4CENSUS: 4DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Arreguin Renee and Licensee Irene Hatton-BurnitzkiTIME COMPLETED:
03:45 PM
NARRATIVE
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On 04/08/24, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry by Administrator Arreguin Renee. Inspection conducted with Administrator and Licensee Irene Hatton-Burnitzki. One resident was present during the inspection the rest were at day program.

LPA observed 7-day supply of non-perishable foods and a 2-day supply of perishable foods observed. At 11:25 AM LPA observed Knives and cleaning supplies unlocked in the kitchen cabinet and under the sink. Additional cleaning and Chemical supplies are kept in locked cabinet in the garage. At 12:20 PM LPA observed Fire extinguisher was expired with a service date of 3/21/2023. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place.

All pathways, entrances and exits were clear from obstruction. The facility was observed to be at a comfortable temperature, in good repair. Common areas were properly furnished and well-lit throughout. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and recliners for residents, adequate outside space for rest and recreational. LPA toured outside and observed sufficient seating under patio area. Pool observed with a fence and a locked gate. Backyard gate is self-closing and self-latching. Last fire drill conducted on 3/24/2023. At 11:23 PM LPA reviewed resident's medication, MARS, and Centrally Stored Medication and Destruction Record (CSMDR) and observed medication was not logged in the log.

Continued to LIC809C…
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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 5


Document Has Been Signed on 04/08/2024 03:19 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: AUGDON SENIOR CARE HOME
FACILITY NUMBER: 547201900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in 2 out of 2 cleaning supplies observed unlocked under the kitchen sink and paint cans in the activities closet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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Licensee removed chemicals and paint and placed them in a locked area. Citation cleared during inspection.
Type A
Section Cited
CCR
87203
87203 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 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 when the fire extinguisher was observed to be last serviced on 3/21/2023, which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 04/09/2024
Plan of Correction
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Licensee agrees to purchase a new fire extinguisher or have the current fire extinguisher serviced and submit proof of purchase or service by the POC due date to the Fresno CCL office.
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: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: AUGDON SENIOR CARE HOME
FACILITY NUMBER: 547201900
VISIT DATE: 04/08/2024
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Resident Admission agreement needs/services plan, and emergency identification is up to date. Staff files reviewed and complete. Staff verified to have CPR/First aid training.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 4/15/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with
appeal rights were provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
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