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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606938
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:53:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20241022152637
FACILITY NAME:AUTUMN HILLS RESIDENTIAL HOME, INC.FACILITY NUMBER:
197606938
ADMINISTRATOR:AUGUSTINE KEHINDEFACILITY TYPE:
740
ADDRESS:43129 LEMONWOOD DRIVETELEPHONE:
(661) 943-8194
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kehine AugustineTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff blocked exit to resident's room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit at this facility for the above allegation. LPA was greeted and granted accesses by staff#1 (S1). S2 contacted the administrator via telephone and LPA explained the reason for the visit. The administrator, Augustine Kehinde informed LPA they would meet LPA at the facility.

Allegation: Staff blocked exit to resident's room. In regards to the allegation, it was reported a wooden board was being used to block the only exit to resident #1's (R1's) bedroom. To investigate the allegation LPA toured the facility to ensure the health and safety of resident's. LPA did not observe a wooden plank or board anywhere in the facility. From approximately 12:23 p.m. to 1:00 p.m. LPA interviewed four (4) residents, the administrator, S1 and S2. LPA did not obtain information about the allegation from R1's interview. At approximately 1:25 p.m. LPA obtained copies of R1's physician report, unusual incident report and mental health appointments. (Continued to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20241022152637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AUTUMN HILLS RESIDENTIAL HOME, INC.
FACILITY NUMBER: 197606938
VISIT DATE: 10/29/2024
NARRATIVE
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(Continued from LIC9099)

At 2:23 p.m. LPA interview two (2) more residents. LPA's review of R1's physician report revealed the physician did not select yes or no for "able to leave the facility unassisted" question. According to the administrator the primary care physician was leaving the response up to R1 psychiatrist. According to the administrator the psychiatrist had verbally told them R1 cannot leave the facility unassisted. LPA's interview with administrator and S1 revealed R1 has gotten lost in the past and tends to pick up trash from the floor to eat. LPA's interview with S2 confirmed there was a piece of wood holding R1's door closed because R1 is prone to leaving the facility unassisted. LPA's interview with the Administrator confirms he found out about the wood and immediately instructed his staff to throw it away. According to the administrator R1 has had an escalation of behaviors due to R1's mental health diagnosis. Administrator states his staff informed him R1 has made threats to staff and residents prompting staff to keep R1 in their room afraid R1 may attack another resident. Interview with four (4) out of six (6) residents that responding to LPA's questioning state they feel safe with staff at the facility and are able to leave the facility when they want. Administrator states in-service training has been conducted regarding residents personal rights. Administrator provided copies of in-service sign in sheet to LPA. Based on LPA's interviews the allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted. Appeal rights provided and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241022152637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AUTUMN HILLS RESIDENTIAL HOME, INC.
FACILITY NUMBER: 197606938
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
CCR
87468.1(a)(6)
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(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building or on facility premises by day or night. This requirement is not met as evidenced by:
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The administrator has thrown away the wood used to obstruct bedroom door and has had inservice training with his staff relating to personal accommodations and services. POC cleared today.
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Based on interviews, the licensee did not comply with the regulation cited as staff would obstruct R1's bedroom door preventing R1 from exiting which posed an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3