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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209492
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:18:59 AM

Document Has Been Signed on 11/07/2024 11:18 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AUTUMN RIDGE ASSISTED LIVINGFACILITY NUMBER:
107209492
ADMINISTRATOR/
DIRECTOR:		DHALIWAL, KARENFACILITY TYPE:
740
ADDRESS:14280 W STANISLAUS AVETELEPHONE:
(661) 972-4646
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY: 54CENSUS: 34DATE:
11/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Karen DhaliwalTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 11/07/24, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management- deficiencies inspection regarding incident reports that received from facility. LPA met with Administrator Karen Dhaliwal.

The purpose of the today's visit is to follow up on the three incident reports that was reported to department. First incident that had occurred on 09/18/24 where R1’s medications was not administered. S1 had put all R1’s medications on hold without a doctor’s order on 08/25/24. Second incident occurred on 10/22/24, S2 administered R5’s medication to R2. The third incident occurred on 10/24/24, S4 had administered R4’s medication to R3.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

Exit Interview conducted. A copy of this report and appeal rights was provided to Administrator, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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Document Has Been Signed on 11/07/2024 11:18 AM - It Cannot Be Edited


Created By: Mai Yang On 11/07/2024 at 10:04 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AUTUMN RIDGE ASSISTED LIVING
FACILITY NUMBER: 107209492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2024
Section Cited
CCR
87465(c)(2)

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87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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S1, S2 and S4 was retrained on medications regulation which will include administering medications. Copies of trainings materials and proof of staff retrained will be submitted to department by 11/08/24.
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Based on interviews and records review, on 09/18/24, R1’s medications were not administered to the resident and was put on hold. R1's medications was placed on hold by S1 without a doctor’s order on 08/25/24. On 10/22/24, S2 administered R5’s medication Lorazepam 1 mg to R2. On 10/24/24, S4 administered R4’s medication Hydralazine HCL 25mg to R3, which poses an immediate health and safety risks 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.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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