<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201900
Report Date: 03/18/2022
Date Signed: 03/18/2022 01:49:05 PM

Document Has Been Signed on 03/18/2022 01:49 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 HOMEFACILITY NUMBER:
547201900
ADMINISTRATOR:RENEE AGUILARFACILITY TYPE:
740
ADDRESS:2610 S. DOLLNER STREETTELEPHONE:
(559) 734-4459
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Licensee Irene Hatton-Burnitzki and Renee Aguilar AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/18/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Licensee Irene Hatton-Burnitzki. LPA conducted facility tour with Licensee. Administrator Renee Aguilar arrived shortly. One resident was present during the inspection.

Upon entry facility staffs was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings not observed.

Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage and under kitchen. All resident’s bedrooms toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant. All bathrooms are observed with securely fastened grab bars and non-skid mat. Trash bin observed without lid. LPA observed hand washing posting by all bathroom sinks. LPA checked residents’ locked medications. LPA observed 30-day PPE supplies.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All four resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 3/24/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 500, and Lic 9020. LPA received copy of updated Administrator Certificate, current liability insurance, Lic 402, and current Lic 610E.

Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 1