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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800841
Report Date: 01/27/2022
Date Signed: 01/27/2022 04:28:02 PM

Document Has Been Signed on 01/27/2022 04:28 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: 4DATE:
01/27/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria Mendez, LicenseeTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Salia Walker and Elsie Campos arrived at the facility unannounced to conduct a required Annual visit at 2:30 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Licensee Maria Mendez at 3:35 p.m., and explained the reason for the visit.

The LPAs toured the physical plant areas inside and outside at 3:18 p.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPAs observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPAs observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Between 3:31 p.m. and 3:33 p.m., hot water temperatures measured between 105.3 and 109.2 degrees Fahrenheit in the common and private bathroom(s).
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 105.9 degrees Fahrenheit at 3:20 p.m.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPAs observed required postings in the hallway. One fire extinguisher was observed to be fully charged and serviced.
BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There was one (1) body of water noted, and all entrance ways were locked and secured. The garage contains additional nonperishable and perishable food items. The garage is attached to the facility.
Continued LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AUTUMN MANOR, LLC
FACILITY NUMBER: 565800841
VISIT DATE: 01/27/2022
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INFECTION CONTROL: During today’s visit, the LPAs spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC809 (FAS) - (06/04)
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