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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606938
Report Date: 05/29/2025
Date Signed: 05/29/2025 03:15:36 PM

Document Has Been Signed on 05/29/2025 03:15 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
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
ADMINISTRATOR/
DIRECTOR:		AUGUSTINE KEHINDEFACILITY TYPE:
740
ADDRESS:43129 LEMONWOOD DRIVETELEPHONE:
(661) 943-8194
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 6DATE:
05/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Augustine KehindeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 05/29/2025 Licensing Program Analyst (LPA) Evelin Rios conducted an Annual Required visit and inspection of the facility. The inspection tool was used for todays visit. LPA met with Staff#1 (S1) who granted access and contacted the Administrator, Augustine Kehinde. LPA met the administrator shortly after and explained the reason for the visit. Physical tour was conducted and LPA observed the following: At entry LPA observed appropriate postings on the wall near the front door and the hallway leading to residents bedrooms and bathroom.

Kitchen: At 11:32 AM, LPA observed S1 washing dishes. The kitchen appliances and fixtures were functional. LPA also observed enough 7 day non-perishable amount of food and a 2 day perishable supply of food in the facility. Staff #2 (S2) arrived to the facility at 11:39 a.m., with more groceries.

Bedrooms: There are four (04) resident bedrooms in total. Two (02) bedrooms are shared and two (02) bedrooms are for private use. Resident bedrooms were observed clean and clear of clutter, properly furnished with appropriate beds, night stands and chairs. Doors in bedrooms leading to the outside had auditory alarms that were observed functional. In the hallway closet leading to bedrooms labeled 2 and 3 LPA observed extra bed and bath linens.

Bathrooms: There are three (03) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. From 12:27 p.m. to 12:30 p.m. LPA took the hot water temperature from two (02) out of three (03) bathroom and they measured between 110.1 and 119.1 degrees Fahrenheit, within regulation.
(Continue on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
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 3
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/29/2025
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Common Areas: These included two (02) living rooms, and the dining area. The common areas were properly furnished. The dining room has a table with chairs to sit the capacity of the facility. The living rooms have televisions and couches that were observed in good repair.

Outside/Surrounding Grounds: LPA observed that the entry/exits were free of obstruction. There is a shaded area for residents to use and furniture appropriate for outdoor use. The backyard is sufficient in space for outdoor exercise and activities. No bodies of water observed.

Laundry/Garage: The laundry area is located in the attached garage. there is access to the garage inside the facility. The door leading to the garage was observed locked. Cleaning supplies and detergents are kept locked in the garage. The garage is used for facility storage.

STAFF WORKSTATION: Facility has a work station for staff. The work station is located by the dining area. Facility files and resident records are stored in a locked cabinet in the workstation. Medications are stored in a locked cabinet in the work station. A first aid kit is kept in the locked cabinet with the medications.

Smoke detectors/carbon monoxide. All resident rooms are equipped with smoke detectors and the facility's smoke detectors are hard wired and interconnected. There is a pull station located at the front entrance. The carbon monoxide detector is located in the hallway. Detectors were tested by administrator at 1:17 p.m., and were observed operational. The fire extinguishers are located by the entry and in the kitchen. They were observed fully charged with service date 04/21/25.

From 1:20 p.m. to 2:30 p.m., LPA reviewed six (06) of six (06) resident records and (3) staff records. Records were observed locked in a workstation cabinet, complete and up-to-date. At 2:31 p.m., LPA reviewed residents' centrally stored medication and medication records. LPA observed medications are centrally stored and locked in the work station cabinet. LPA collected a copy of the Certificate of Liability Insurance, and LIC500. LPA reviewed administrator certificate, LIC610E, and last Fire Drill training conducted on 02/22/2025.

No deficiency cited during today’s visit. Exit interview conducted and copy of this report signed and provided
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
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