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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423366
Report Date: 04/29/2024
Date Signed: 04/29/2024 10:48:36 AM

Document Has Been Signed on 04/29/2024 10:48 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AUTUMN HILLFACILITY NUMBER:
336423366
ADMINISTRATOR/
DIRECTOR:		CECILIA BARNAFACILITY TYPE:
740
ADDRESS:11002 CLEVELAND AVETELEPHONE:
(951) 543-4288
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 3DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Cecilia Barna - LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:03 AM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Licensee Cecilia Barba, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and three (3) residents present. The facility is licensed for six (6) residents, whom may be non-ambulatory, with one (1) who may be bedridden. The facility has a hospice waiver for four (4) residents. A dementia program is also on file. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present.The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were stored and inaccessible to clients. The sharp and dangerous objects were observed to be locked and inaccessible to residents. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed two (2) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Three (3) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AUTUMN HILL
FACILITY NUMBER: 336423366
VISIT DATE: 04/29/2024
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Resident medication was centrally stored and locked in a cabinet located in the kitchen. LPA reviewed medications prescribed to the residents and found all medication listed on MARS and all required labeling was found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Fire extinguishers were fully charged and inspected.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Licensee Barna.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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