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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606938
Report Date: 06/04/2023
Date Signed: 06/04/2023 03:37:12 PM


Document Has Been Signed on 06/04/2023 03:37 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:AUTUMN HILLS RESIDENTIAL HOME, INC.FACILITY NUMBER:
197606938
ADMINISTRATOR:AUGUSTINE KEHINDEFACILITY TYPE:
740
ADDRESS:43129 LEMONWOOD DRIVETELEPHONE:
(661) 943-8194
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
06/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Augustine KehindeTIME COMPLETED:
03:45 PM
NARRATIVE
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On 06/04/2023 at 9:30 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA observed appropriate Covid-19 postings on the outside wall by the front door. LPA was greeted by staff #1 (S1) and granted access. S1 called the Administrator designee and notified Administrator designee Adebisi Ogunsaju, LPA was at the facility. Administrator Augustine Kehinde and administrator designee met LPA shortly after and LPA explained the reason for the visit.

At 10:00 a.m. LPA and the administrator toured the physical plant of the facility inside and outside, and the following was observed:
Living room: There are 2 living room areas and both were clean and properly furnished. LPA observed one (1) of two (2) fire extinguisher fully charged last serviced 04/10/2023.
Kitchen/ Dinning area: LPA observed breakfast had just finished and S1 was clearing the table and then washing the dishes. The kitchen was observed to be clean and clear of clutter once S1 was done. Appliances and fixtures were functioning properly. LPA observed cleaning products kept locked under the kitchen sink. LPA observed knives locked in a bottom cabinet. LPA observed a sufficient amount of 2- day perishable and 7-day non-perishable food at the facility; properly stored. LPA observed a second fridge in the kitchen meant for staff only. LPA observed a second fire extinguisher fully charged with a last serviced date of 04/10/2023. Dining area had appropriate table and chairs to sit the capacity of the facility.
Bedrooms: LPA inspected five (5) out of five (5) bedrooms. Four (4) out of Five (5) bedrooms are for resident use. One (1) bedroom is currently shared by two (2) residents. LPA observed each resident room to be properly furnished with a bed, bedding, night stand, chair, and with sufficient lighting and storage. LPA observed extra linens in a hallway cabinet outside the bedrooms.
Bathrooms: The facility has 3 bathrooms. LPA took water temperature at 12:44 p.m. from one (1) out of the three (3) bathroom's sink and temperature read 117.3 degrees F. LPA observed the bathrooms to be clean and properly supplied with toilet paper, soap, paper towels. (LIC 809-C onto next page)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AUTUMN HILLS RESIDENTIAL HOME, INC.
FACILITY NUMBER: 197606938
VISIT DATE: 06/04/2023
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(LIC 809-C continued)
Laundry/Garage: Laundry area is located in the garage. Garage is inaccessible to clients. Detergents are kept locked in the garage.
Surrounding Grounds: Entry and exits were free from obstructions. There is a small covered patio. LPA observed appropriate furniture for residents to use. There is a small shed that was locked and being used to store extra facility supplies.
Interviews: From 10:25 a.m. to 11:20 a.m. LPA conducted interviews with four (4) out of four (4) residents and three (3) out of three (3) staff present, including the administrator.
Resident/Staff Records: From 11:20 a.m. to 12.24 p.m. LPA reviewed facility records. Review of resident records revealed one (1) out of four (4) resident records had incomplete information on their physician's reports and did not have a medical assessment on file. According to Administrator the primary physician visits facility in person and primary physician did not complete physician's report entirely or attached a copy of the medical assessment report. Administrator states, they will call physician on Monday to obtain records. LPA review of record revealed the same resident #3 (R3) did not have a reappraisal/needs and services plan for their change in condition (current condition).

At 1:00 p.m. LPA observed Administrator test a dual smoke and carbon monoxide detector. Detector is hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly.

Medication: Medication Records were reviewed for proper documentation. Centrally stored medications are maintained in a locked cabinet by the kitchen and dining area. Medications were observed locked. Refills are either done automatically every 30 days, or ordered by the physician. From 2:00 p.m. to 3:00 p.m. LPA and administrator reviewed Centrally Stored Medication Records and medication for (4) four out of (4) residents in care. CSMDR are provided by the pharmacy for three (3) out of four (4) residents. Resident #1 (R1) has a different pharmacy from the other residents and CSMDR is filled in by staff at the facility.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during todays visit (refer to 809-D). Exit Interview Conducted. A Copy of appeal rights and this report provided.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/04/2023 03:37 PM - 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: AUTUMN HILLS RESIDENTIAL HOME, INC.
FACILITY NUMBER: 197606938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one out of four residents in care by not ensuring a complete annual medical assessment was on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Licensee will contact physician for resident # 3(R3) identified to have an incomplete medical assessment information for current year. Licensee will submit a copy of physician's report or medical assessment with required information to LPA by POC due date.
Type B
Section Cited
CCR
87463(a)
87463(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one out of four residents’ reappraisals which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Licensee will complete a reappraisal/ needs and services plan for resident # 3 (R3) identified to have a change in condition and submit copy to LPA by POC due date.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2023
LIC809 (FAS) - (06/04)
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