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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423366
Report Date: 07/01/2021
Date Signed: 07/01/2021 12:20:34 PM

Unsubstantiated


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
06/29/2021 and conducted by Evaluator Christine Le
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210629125346
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: 5DATE:
07/01/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Cecilia BarnaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff yelled at a resident while in care
Resident sustained pressure injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to investigate the above allegations. LPA met with administrator Cecilia Barna.

LPA toured the facility, conducted interviews, and reviewed facility files. The first allegation indicates that on 6/28/21 Staff 1 (S1) yelled at Resident 1 (R1) and told the resident to 'shut up'. LPA conducted interviews with residents and staff. LPA observed conflicting information during the interviews. R1 and another resident reported that the facility staff are nice, do not yell, and take good care of them. The second allegation indicates that R1 sustained pressure injuries while in care. LPA was informed that R1 was admitted to the facility on 6/18/21 and receives home health services for wound care. LPA was informed that R1 has pressure injuries on both heels, back, and bottom. LPA was advised that the pressure injuries are healing and the facility is working alongside with the home health agency to take care of them. LPA reviewed the home health documentation and observed that R1 had the pressure injuries upon admission.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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 2
Control Number 18-AS-20210629125346
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: 07/01/2021
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2