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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203991
Report Date: 06/13/2024
Date Signed: 06/17/2024 12:49:11 PM


Document Has Been Signed on 06/17/2024 12:49 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:AUGDON SENIOR CARE HOME #2FACILITY NUMBER:
547203991
ADMINISTRATOR:ARREGUIN, RENEEFACILITY TYPE:
740
ADDRESS:134 COLORADO AVETELEPHONE:
(559) 684-8831
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:4CENSUS: 4DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Administrator, Renee ArreguinTIME COMPLETED:
02:28 PM
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On 06/13/24, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required annual Inspection. LPA was greeted by Direct Support Personnel (DSP II), stated the purpose of the visit and was allowed entry into the facility. DSP II contacted the Administrator, who arrived to the facility shortly after.

LPA toured the facility inside and out. Administrator on record is Rene Arreguin, Certificate #6020726740, Exp. 10/28/24.

LPA observed 2 residents in care at the time of visit. Facility is a 4 bedroom 2 bathroom home. The front bedroom is designated as an office Bathrooms were observed to have grab bars by the toilets and a grab bar in the shower used by residents. Residents in care receive Regional Center services. Resident bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Facility temperature was 78 degrees F.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 107 degrees F. Trash can with lid and hand washing postings were observed.

Medications were observed to be locked in a cabinet located in the entry. Cleaning supplies were observed to be locked in the garage. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored.

Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 02/07/24. First aid kit was observed and contained all required items. Internet devices and a working phone line were observed to be available for residents in care.

(Continued on 809-C)
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: AUGDON SENIOR CARE HOME #2
FACILITY NUMBER: 547203991
VISIT DATE: 06/13/2024
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(Continued from 809)

Required postings were observed for Non-discrimination LGBTQ-A+, Personal Rights of Residents in RCFE (87468.1 and 87468.2), facility's visitation policy and LETUSNO Complaint Poster, (PUB475), Ombudsman poster and Resident Council Rights were observed.

No residents are receiving Hospice services residents or receiving Home Health care service. A sample of resident and staff files were reviewed and observed to have the required forms and training records.

No deficiencies cited on today's visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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