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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203991
Report Date: 08/24/2023
Date Signed: 08/24/2023 06:30:10 PM


Document Has Been Signed on 08/24/2023 06:30 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: 3DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Renee Arreguin, AdministartorTIME COMPLETED:
04:30 PM
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On 08/24/23, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. Administrator on record is Renee Arreguin, Certificate #6020726740, Exp. 10/28/2024.

There are currently 3 residents in the home. No residents are receiving Hospice services residents or receiving Home Health care service. There are no resident's receiving Hospice Care plans or Home health services. A sample of resident and staff files were reviewed and observed to have the required forms and training records.

LPA toured the facility inside and out and observed the facility temperature read at 74 degrees F. Resident bedrooms were observed to have the required lighting/furnishings and are free from odor and passageway obstruction/fire hazards. Bathrooms were observed to have operational lights, running water, and non-slip floors. Hot water temperature tested at 108 degrees F.

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 Complaint Poster. Resident Council Rights were observed.

Cleaning supplies were observed to be locked in . 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. Menus for the facility were observed.

(Continued LIC 809-C)

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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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: 08/24/2023
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(Continued from 809)

Carbon monoxide detectors were observed to be operational. Fire Extinguisher was observed with a service date of 02/06/23. First aid kits were observed to contain all required items.

Medications were observed to be in a locked closet in the main living area. Quarterly Emergency Disaster Drill logs were observed. Last fire drill was on 07/25/23.

LPA is requesting the following documents be submitted to the Fresno CCL office by 09/06/2023: Designation of Facility Responsibility (LIC308), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), Surety Bond.

An exit interview was conducted with Administrator. A copy of this report was discussed and provided at the time of visit. 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: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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