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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800841
Report Date: 09/24/2021
Date Signed: 09/24/2021 06:11:22 PM

Document Has Been Signed on 09/24/2021 06:11 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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: 5DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Giovanni FulgentesTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Teresa Camara and Ashley Smith conducted an unannounced Required -1 Year inspection. LPAs met with Administrator Giovanni Fulgentes and Maria Mendez and explained the reason for the visit.

Today's evaluation included but was not limited to: building and grounds, residents' rooms, bathrooms, hot water temperature (read at 102.7 degrees F) in bathrooms, common areas, food and first aid supplies. LPA observed lamps/lights as well as sufficient furnishings and linens for each room. LPA observed fire extinguisher fully charged. Centrally stored medicines are kept in a locked cabinet in the hallway near the family room/dining room area. Grab bars and non-skid materials were present in the bathrooms. LPA observed facility to be a comfortable temperature throughout the visit. Smoke alarms and carbon monoxide detectors were tested and were operable at the time of the visit. Indoor and outdoor area toured passageways were free from obstruction. LPA reviewed resident records and medications. LPA reviewed staff records. During facility tour, LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed.

During the facility tour on 09/24/21 at 09:15 a.m. LPA observed over the counter ointments and shampoo stored in an unlocked drawer of the dresser in bedroom 3. Later during the tour, at 09:25 a.m., LPA observed hairspray on a nightstand in bedroom 1. While reviewing medications at 03:00 p.m., LPA observed over the counter medications with no physician orders for Residents 2, 3, 4, and 5 (R2, R3, R4, R5). LPA also observed there were no physician orders for prescription medications for R4.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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 3
Document Has Been Signed on 09/24/2021 06:11 PM - It Cannot Be Edited


Created By: Teresa Camara On 09/24/2021 at 03:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AUTUMN MANOR, LLC
FACILITY NUMBER: 565800841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705(f)(2) Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as over the counter medications were observed in bedroom 3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2021
Plan of Correction
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Administrator were made inaccessible during today's visit. Plan of correction met.
Request Denied
Type A
Section Cited
CCR
87705(g)(1)
87705(g)(1) Care of Persons with Dementia
(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1) Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as personal hygiene items were accessble in bedrooms 1 and 3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2021
Plan of Correction
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Hygiene items were made in.accessible. Plan of correction met
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/24/2021 06:11 PM - It Cannot Be Edited


Created By: Teresa Camara On 09/24/2021 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AUTUMN MANOR, LLC
FACILITY NUMBER: 565800841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(3)
87458 (b)(3) Medical Assessment
(b) The medical assessment shall include, but not be limited to: (3) A record of current prescribed medications, and an indication of whether the medication should be centrally stored, pursuant to Section87465(h)(1).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 4 out of 5 residents lacked physicians' orders for medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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Administrator will obtain physician orders for medications and provide copies of the orders to CCL on or before 10/01/2021.
Type B
Section Cited
CCR
87303(e)(2)
87303(e)(2) Maintenance and Operation. (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as water temperature measured below regulation which poses a potential health and safety risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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The Administrator will adjust the water heater, and keep a five day log to ensure water is within regulation. Submit log to CCL by 10/1/2021
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021


LIC809 (FAS) - (06/04)
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