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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201900
Report Date: 02/06/2023
Date Signed: 02/06/2023 12:14:13 PM

Document Has Been Signed on 02/06/2023 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
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:
02/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Licensee Irene Hatton-Burnitzki TIME COMPLETED:
12:15 PM
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On 2/06/23, Licensing Program Analyst (LPA) K.Kaur 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.

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 and cough etiquette postings not observed. Facility staff observed with face masks.

LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Cleaning supplies were stored and locked in cabinet in the garage and under kitchen sink. All resident’s bedrooms toured and observed to be adequately furnished and well lit. LPA observed 4 bedrooms that are single occupant. All bathrooms are observed with securely fastened grab bars and non-skid mat. LPA observed hand washing posting by all bathroom sinks. LPA checked residents’ locked medications. LPA observed 30-day supply of PPE and medication. The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. Resident records reviewed to have updated emergency contact information.



No deficiencies issued during this inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 2/13/2023: 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 for LIC9020. An exit interview was conducted with
Administrator. Report signed on-site and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2023
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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