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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423366
Report Date: 07/20/2020
Date Signed: 07/07/2021 08:58:30 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2020 and conducted by Evaluator Elecia Weathersby
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200505135802
FACILITY NAME:AUTUMN HILLFACILITY NUMBER:
336423366
ADMINISTRATOR:CECILIA BARNAFACILITY TYPE:
740
ADDRESS:11002 CLEVELAND AVETELEPHONE:
(951) 543-4288
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 2DATE:
07/20/2020
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Cecelia BarnaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility did not provide a refund to the responsible party
INVESTIGATION FINDINGS:
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LPA Weathersby reviewed complaint allegation:
#1 Facility did not provide a refund to the responsible party:

LPA Weathersby made phone contact with Administrator Cecelia Barna on 6/25/2021 to confirm that LPA Parker previously discussed the elements of Allegation #1. Mrs. Barna confirmed the discussion with LPA Parker.

LPA Susan Parker contacted the facility via telephone, due to COVID-19, to conclude this complaint investigation for the above allegation. LPA Parker spoke with Administrator Cecelia Barna.

Continued on next page LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Elecia Weathersby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2020 and conducted by Evaluator Elecia Weathersby
COMPLAINT CONTROL NUMBER: 18-AS-20200505135802

FACILITY NAME:AUTUMN HILLFACILITY NUMBER:
336423366
ADMINISTRATOR:CECILIA BARNAFACILITY TYPE:
740
ADDRESS:11002 CLEVELAND AVETELEPHONE:
(951) 543-4288
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 2DATE:
07/20/2020
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Cecelia BarnaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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LPA Elecia Weathersby and LPA Susan Parker conducted a joint investigation regarding Allegation #2: Staff hit resident.

On 7/20/2020, LPA Susan Parker contacted the facility via telephone, due to COVID-19, to conclude this complaint investigation for the above allegation. LPA Parker spoke with Administrator Cecelia Barna.

The investigation consisted of the following: LPA Parker conducted interviews with the administrator, witness #1, staff #1, and LPA reviewed a preadmission fee explanation page.

The investigation revealed the following: When LPA Parker spoke with witness #1, the witness said they did not want to include the above allegation. Witness #1 said there were times when resident #1 was hallucinating and the witness was pretty satisfied with the care resident #1 was receiving.
LPA Parker spoke with Cecelia Barna and she said she never hit resident #1. LPA Parker spoke with staff #1 and the staff said they never hit resident #1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Elecia Weathersby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200505135802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AUTUMN HILL
FACILITY NUMBER: 336423366
VISIT DATE: 07/20/2020
NARRATIVE
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Continued from previous page LIC9099A

On 5/9/2021, LPA Weathersby interviewed S1, S2,who denied hitting or witnessing anyone hit R1. LPA Weathersby also interviewed R2, who denied ever being hit or witnesses other residents being hit while residing in the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore the allegation is Unsubstantiated.

LPA Weathersby conducted an exit interview with Cecelia Barna and a copy of this report was provided to her.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Elecia Weathersby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200505135802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AUTUMN HILL
FACILITY NUMBER: 336423366
VISIT DATE: 07/20/2020
NARRATIVE
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Continued from previous page LIC9099

The investigation consisted of the following: LPA Parker conducted interviews with the administrator, witness #1, staff #1, and LPA reviewed a preadmission fee explanation page.

The investigation revealed the following: Resident #1 moved into Autumn Hill in February 2020. In April 2020, resident #1's family paid the resident's rent for 4/13/20 through 5/12/20. Resident #1 passed away on 4/15/20. After resident #1 passed away, the administrator did not give the resident's family a refund. The family was told there was no refund, based on a Preadmission Fee Explanation which the family signed. LPA reviewed the Preadmission Fee Explanation page, but this document was not an Admission Agreement. The family of resident #1 said they never signed an admission agreement, and the administrator could not produce an admission agreement. LPA explained to Cecelia Barna that she could not withhold the refund because she did not complete an admission agreement with resident #1's family, and the family was not aware of the facility's refund policy. LPA Parker spoke with Cecelia Barna on 7/20/20 and she agreed she would send the required refund to the family of resident #1.

Based on the preponderance of evidence standard, the allegation is Substantiated.

California Code of Regulations, Title 22, Division 6, Chapter 8 is cited on the attached LIC 9099D.

LPA Weathersby commenced an unannounced in-person visit with Administrator, Cecelia Barna, LPA reviewed Allegation #1 with the Administrator, an exit interview was conducted and a copy of this report was provided to her.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Elecia Weathersby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200505135802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AUTUMN HILL
FACILITY NUMBER: 336423366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2021
Section Cited
HSC
1569.652
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HSC 1569.652 (d) Any fee charged by a licensee of a residential care facility for the elderly, whether prior to or after admission, shall be clearly specified in the admission agreement. This requirement is
not met as evidenced by:
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No action required. Administrator issued refund on 7/21/2021.
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Based on interviews, and facility document reviews, the licensee failed to issue a refund to the resident's estate 15 days after the resident's personal property was removed. which poses a potential health and safety risks to persons in care. R1 passed away on 4/15/20.
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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: Efren Malagon
LICENSING EVALUATOR NAME: Elecia Weathersby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5