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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209224
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:40:06 AM

Document Has Been Signed on 08/10/2022 11:40 AM - 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 #3FACILITY NUMBER:
547209224
ADMINISTRATOR:AUGDON-RUDOLPH, FRANCESFACILITY TYPE:
740
ADDRESS:216 ALBERT AVENUETELEPHONE:
(559) 592-1875
CITY:EXETERSTATE: CAZIP CODE:
93221
CAPACITY: 4CENSUS: 3DATE:
08/10/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrators Frances Augdon-Rudolph and Renee ArreguinTIME COMPLETED:
11:45 PM
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Licensing Program Analyst (LPA) K.Kaur conducted a Pre-licensing Inspection on this date. LPA met with Administrators Frances Augdon-Rudolph and Renee Arreguin. A tour of the facility was conducted together.

This is an existing facility with 3 residents in placement. The facility was observed to be at a comfortable temperature, clean, in good repair. No passageway obstructions or fire hazards were observed inside or outside. 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.

Perishable and non-perishable food supply appeared adequate. Knives will be locked in the kitchen cabinet. Cleaning and Chemical supplies are kept in locked in the laundry room. 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. Hot water temperature measured at 114 degrees F. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place, hand soap and paper towels available for use. Trash cans with tight fitting lids are in place.

Fire extinguisher was serviced on 12/7/2021 and fully charged. Medications and first aid kit are locked in the kitchen cabinet. Complaint poster posted, resident council info posted, residents' rights posted, emergency disaster plan posted. Gate is self-closing and self-latching.

Component III was also conducted and completed. Exit interview was conducted. Pre-licensing requirements
were met. An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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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