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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201900
Report Date: 04/14/2025
Date Signed: 04/14/2025 02:29:12 PM

Document Has Been Signed on 04/14/2025 02:29 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/
DIRECTOR:		RENEE ARREGUIN (AGUILAR)FACILITY TYPE:
740
ADDRESS:2610 S. DOLLNER STREETTELEPHONE:
(559) 303-8783
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
04/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Administrator Arreguin Renee and Licensee Irene Hatton-BurnitzkiTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 04/14/25, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry by Licensee Irene Hatton-Burnitzki. Administrator Arreguin Renee arrived a short while later.

LPA observed 7-day supply of non-perishable foods and a 2-day supply of perishable foods observed. Sharps locked in kitchen cabinet. Cleaning supplies locked under kitchen sink. Additional cleaning and Chemical supplies are kept in locked cabinet in the garage. Fire extinguisher observed with a service date of 1/21/2025. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place. All pathways, entrances and exits were clear from obstruction. The facility was observed to be at a comfortable temperature, in good repair. Common areas were properly furnished and well-lit throughout. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and recliners for residents, adequate outside space for rest and recreational. LPA toured outside and observed sufficient seating under patio area. Pool observed with a fence and a locked gate. Backyard gate is self-closing and self-latching. Last fire drill conducted on 12/5/2024. Resident and Staff files reviewed and complete. Staff verified to have CPR/First aid training. LPA reviewed resident's medication, MARS, and Centrally Stored Medication and Destruction Record (CSMDR).

No Deficiencies observed during inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 4/21/2025: 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 LIC9020.

Exit interview conducted with Licensee. A copy of this report was discussed and provided to Licensee, whose signature on this form confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Kamaldeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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