547209224-8-2-2023-24-AS-AWAN-CUBQKA-20230802121402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547209224
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:14:17 PM

Document Has Been Signed on 08/02/2023 12:14 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 #3		FACILITY NUMBER:	547209224
ADMINISTRATOR:	AUGDON, FRANCES		FACILITY TYPE:	740
ADDRESS:	216 ALBERT AVENUE		TELEPHONE:	(559) 592-1875
CITY:	EXETER	STATE: CA	ZIP CODE:	93221
CAPACITY:	4	CENSUS: 2	DATE:	08/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	House Manager, Whitney Hatton		TIME COMPLETED:	12:28 PM

NARRATIVE

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On 08/02/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA knocked on the door and did not receive a response. LPA contacted Administrator, Renee Arreguin via telephone and disclosed the purpose of today's visit. LPA received verbal permission to meet with House Manager, Whitney Hatton who arrived a short time later.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed a strong urine odor in bedroom / bathroom 2. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and shower areas, non-skid mats were observed. LPA observed the wall and shower handle in the shower area to be in need of cleaning and repair. Hot water measured at 114.7 degrees F in bathroom 2 and 112.6 degrees F in bathroom 3. Kitchen toured, appeared clean, food supply was checked. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 01/03/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 07/29/2023. LPA observed two bottles of disinfectants wipes in the storage room accessible to residents in care.

Medications were observed to be administered as prescribed. LPA will return at a later date to review resident and staff records.

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

Exit interview conducted. A copy of this report and appeal rights were discussed and provided to House Manager, Whitney Hatton, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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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Document Has Been Signed on 08/02/2023 12:14 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AUGDON SENIOR CARE HOME #3	FACILITY NUMBER: 547209224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, when two bottles of disinfectant wipes were observed to be accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2023
	Plan of Correction
1 2 3 4	House Manager removed the disinfectant bottles from the storage room and placed the bottles in locked area. POC CLEARED during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/02/2023 12:14 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AUGDON SENIOR CARE HOME #3	FACILITY NUMBER: 547209224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when Bedroom and Bathroom 2 was observed to have a strong urine odor, and the wall in the shower area was in need of repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Licensee agrees to clean the floors in bedroom/bathroom 2 and develop a written plan to ensure R1's soiled linens are cleaned. Licensee also agreed to clean and repair the wall and shower handle faucet in the shower area.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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