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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206271
Report Date: 08/19/2022
Date Signed: 08/19/2022 11:51:42 AM


Document Has Been Signed on 08/19/2022 11:51 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:AUTUMN RIDGE ASSISTED LIVINGFACILITY NUMBER:
107206271
ADMINISTRATOR:JAIME, MORYFACILITY TYPE:
740
ADDRESS:14280 W. STANISLAUS STREETTELEPHONE:
(559) 842-7727
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY:34CENSUS: 27DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Administrator Mory Jaime and Maria Barajas TIME COMPLETED:
12:00 PM
NARRATIVE
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On 8/19/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA met with Administrator Mory Jaime and Maria Barajas and stated the purpose of the visit

Visitor log-in/temperature check, and disinfection station were observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff observed wearing facial coverings.

LPA checked residents’ locked medications and observed a 30-day supply. LPA observed a 7-day supply of
non-perishable foods and a 2-day supply of perishable foods which appeared to be properly stored and labeled. Cleaning and PPE supplies were checked and were locked in storage rooms. Staff records were reviewed for infection control training. At 10AM LPA observed Fire extinguisher in the west wing located next to exit door to be expired with a service date of 11/12/2020. Resident’s files have updated emergency contact information.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 8/26/2022: Mitigation Plan Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site by and printed copy provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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 2


Document Has Been Signed on 08/19/2022 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: AUTUMN RIDGE ASSISTED LIVING
FACILITY NUMBER: 107206271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

87203
FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the
protection of life and property against fire and panic.


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 in 1 out of 1. Fire extinguisher was expired
with a service date of extinguisher 11/12/2020, which poses an immediate health, safety or personal rights risk to persons in
care.
POC Due Date: 08/20/2022
Plan of Correction
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Licensee to either have fire extinguisher serviced or buy new extinguisher and submit pictures as proof of POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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