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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800841
Report Date: 04/30/2021
Date Signed: 04/30/2021 02:05:03 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20201230171804
FACILITY NAME:AUTUMN MANOR, LLCFACILITY NUMBER:
565800841
ADMINISTRATOR:GIOVANNI FULGENTESFACILITY TYPE:
740
ADDRESS:2770 HIGHGATE PL.TELEPHONE:
(805) 582-2188
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
04/30/2021
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Maria Mendez and Giovanni FulgentesTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Residents are not served a variety of foods.
Staff yell in the presence of residents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena conducted a subsequent complaint inspection. The LPAs met with Administrators Giovanni Fuentes and Maria Mendez and explained the reason for the visit.

During the 1/8/2021 visit, the LPA interviewed Ms. Mendez at 3:12pm and requested documents. During today's visit, the LPAs toured the kitchen area at 9:10am; conducted a file review at 9:29am; interviewed current and former residents at 10:08 a.m., 10:14 a.m., and 11:05 a.m.; interviewed staff at 10:27 a.m., and 10:36 a.m.; and, interviewed resident responsible parties at 11:45 a.m., 12:03 p.m., 12:14 p.m., and 12:16 p.m. The LPAs also observed residents consuming meals at the start of the visit and at 11:26 a.m.

CONT to 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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
Control Number 29-AS-20201230171804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AUTUMN MANOR, LLC
FACILITY NUMBER: 565800841
VISIT DATE: 04/30/2021
NARRATIVE
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Regarding the allegation: Residents are not served a variety of foods
It was alleged that the food served at the facility was limited to cold foods. During today's visit, the LPAs reviewed the supply of perishable and nonperishable food and found it to be adequate and of substantial variety. The LPAs observed a variety of meats, fruits, vegetables, grains, and liquids. Interviews revealed that if a resident does not like a meal, they are offered a different option. In general, interviews revealed minimal complaints as it pertains to the variety of food served. During today's visit, the LPAs observed that all special diets were being upheld, and the food offered during the lunchtime service was hot. It appeared that the facility had a variety of both hot and cold meal options. Based on the information obtained, there is insufficient evidence to support the claim that the residents are not served a variety of food. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff yell in the presence of residents.
It was alleged that the staff yell at each other 'very loudly'. During today's visit, the LPAs observed the staff interacting with both the residents and one another in an appropriate tone. Interviews with the responsible parties of the residents whom reside in this facility revealed no concerns or complaints in regards to staff conduct, communication or interaction. Interviews with staff revealed that if staff were too loud, they are reminded to lower their voices, especially if residents are sleeping. Yet, interviews did not reveal concerns or complaints regarding staff yelling or speaking to one another in an elevated tone. Based on the information obtained, there is insufficient evidence to support the claim that staff yell in the presence of residents. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Signatures obtained. A copy of the report was emailed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20201230171804

FACILITY NAME:AUTUMN MANOR, LLCFACILITY NUMBER:
565800841
ADMINISTRATOR:GIOVANNI FULGENTESFACILITY TYPE:
740
ADDRESS:2770 HIGHGATE PL.TELEPHONE:
(805) 582-2188
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
04/30/2021
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Maria Mendez and Giovanni FulgentesTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
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9
Resident's are not bathed at an appropriate time.
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena conducted a subsequent complaint inspection. The LPAs met with Administrators Giovanni Fuentes and Maria Mendez and explained the reason for the visit..

During the 1/8/2021 visit, the LPA interviewed Ms. Mendez at 3:12pm and requested documents. During today's visit, the LPAs toured the kitchen area at 9:10am; conducted a file review at 9:29am; interviewed current and former residents at 10:08 a.m., 10:14 a.m., and 11:05 a.m.; interviewed staff at 10:27 a.m., and 10:36 a.m.; and, interviewed resident responsible parties at 11:45 a.m., 12:03 p.m., 12:14 p.m., and 12:16 p.m. The LPAs also observed residents consuming meals at the start of the visit and at 11:26 a.m.

CONT to 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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 29-AS-20201230171804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AUTUMN MANOR, LLC
FACILITY NUMBER: 565800841
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities. Residents...shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. The Administrator will review the policy and will re-evaluate it. The Administrator will submit a statement as to how the facility will maintain personal rights. Submit statement by 5/7/2021.
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Based on interviews, the licensee did not comply with the section cited above, as residents were showered at an unreasonable time, which poses a potential personal rights risk to persons in care.
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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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20201230171804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AUTUMN MANOR, LLC
FACILITY NUMBER: 565800841
VISIT DATE: 04/30/2021
NARRATIVE
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Regarding the allegation: Resident's are not bathed at an appropriate time.
It was alleged that residents are given showers at 4 a.m. Interviews with staff corroborated the claim that the residents are showered beginning at 4am, and the residents are used to being showered at that time. Staff claimed that this has been the schedule for quite some time. Staff confirmed that there have been occasions where residents have refused to be showered at 4am; thus, they would assist with the shower at a later time.

Interviews with the responsible parties of the residents whom currently reside in this facility revealed varied responses as it relates to the bathing schedule. Not all individuals were aware that the residents were being showered at that time and noted that it was not an appropriate time. However, for those that were aware, they stated that it was the showering schedule and communicated no concerns.

Based on the investigation, there is sufficient evidence to support the claim that residents are not bathed at an appropriate times. The residents whom currently reside at this facility have a diagnosis of dementia; thus, they are unable to adequately communicate their preference as to when they would receive a shower. For those whom were alert, those residents are able to communicate their preference as to when they would like to be showered. Thus, all residents should be afforded a reasonable time frame in which they are showered.
This allegation is Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency is cited: (Refer to LIC 9099-D). Exit interview conducted. Signatures obtained. A copy of the report was emailed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5