<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701631
Report Date: 07/14/2025
Date Signed: 07/14/2025 12:13:43 PM

Document Has Been Signed on 07/14/2025 12:13 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AUTUMN GROVE SENIOR LIVINGFACILITY NUMBER:
342701631
ADMINISTRATOR/
DIRECTOR:		ALBASON, ANDREFACILITY TYPE:
740
ADDRESS:10167 MOSAIC WAYTELEPHONE:
(916) 879-6912
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 0DATE:
07/14/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Andre AlbasonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/14/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived announced at this facility to conduct the prelicensing inspection visit. LPA met with Licensee/Administrator Andre Albason, and stated the purpose of the visit.

Overview: Facility is a one-story home located in a residential neighborhood. Facility will be licensed to serve up to 6 elderly residents, 2 of which are ambulatory and 4 are non-ambulatory . Facility has 4 resident bedrooms and two resident bathrooms. Bedrooms #2 and #3 may be occupied by non-ambulatory residents provided bedroom #4 has no privacy lock as the exit door in bedroom #4 shall be accessible in case of an emergency.

Outdoor Area: Front yard was observed to be maintained and clear of debris and obstruction. There is an area in the backyard equipped with outdoor furniture with umbrella located next to a tree for shade. Outdoor passageways, walkways, driveways, and steps are free from obstructions. Fence and gate are in good repair. No swimming pools/bodies of water at this time.


Residents' Bedrooms: LPA inspected 4 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. Each bedroom has smoke and carbon monoxide detector. Resident bedroom #1 is located near the front door. A fire door was observed leading to the other resident bedrooms. Bedrooms #1 and #3 will be single occupancy. Bedrooms #2 and #4 will be shared. Bedroom #4 has its own bathroom and exits the backyard. This exit will be accessible as an emergency exit.

{Con't to 809-C}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2025
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 6
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)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AUTUMN GROVE SENIOR LIVING
FACILITY NUMBER: 342701631
VISIT DATE: 07/14/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
{Con't from 809} Bathroom: Facility has 2 resident bathrooms. One bathroom in the hallway and the other bathroom is inside bedroom #4. Both bathrooms have working toilets, wash basins and full baths with showers. Both bathrooms are equipped with non-skid flooring and close-lid garbage bins. LPA provided an advisory to install a grab bar in the toilet area for the bathroom in bedroom #4. It was installed during this visit.
Linens & Hygiene Supplies: Adequate supply of linen and hygiene supplies stored in linen closet, located in the resident hallway.
Emergency Phone Numbers, Exit Plan & Menu: Emergency Disaster Plan will be posted & available for review. Two fully charged fire extinguisher were found in the kitchen/dining room and in the resident hallway. Fire extinguishers were last serviced on 1/22/25.
Dangerous Items: Toxins and chemicals were locked/stored under kitchen sink and in the laundry area and are inaccessible to residents.
Water temperature: Hot water temperature was taken in one bathroom and measured at 105*F.
Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in locked drawers.

Smoke Detectors and carbon monoxide: Facility has smoke detectors/carbon monoxide monitor combination. LPA observed one in each resident bedrooms, hallway, living room and in the kitchen/dining room area. They were tested and found in good repair at this time.

Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator/freezer in the kitchen. Advisory was provided to obtain thermometer for both the refrigerator and freezer to ensure regulatory temperature is maintained for proper food storage. Washer and dryer are located in the laundry room, leading to the garage area.

Medications, First-Aid Kit & Records: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet in the kitchen/dining area, available for staff use but inaccessible to residents. There is a medication cabinet that was observed to be locked.

Residents & Staff Files: Applicant will not be handling cash resources of residents at this time but will submit necessary documents for any changes.

{Con't 809-C}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AUTUMN GROVE SENIOR LIVING
FACILITY NUMBER: 342701631
VISIT DATE: 07/14/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
{Con't from 809-C}

Activity Supplies/Materials: During this visit, LPA observed Bingo, Connect Four, Jenga, and books. Advisory was provided for licensee to provide future residents with a variety of activities and choices.

Component III: LPA reviewed Component III with Andre Albason.

The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

An exit interview was conducted and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6