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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606938
Report Date: 04/29/2024
Date Signed: 04/29/2024 02:51:03 PM


Document Has Been Signed on 04/29/2024 02:51 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
WOODLAND HILLS S.RO, 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:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Agustine KehindeTIME COMPLETED:
02:30 PM
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On 04/29/2024 at 9:30 a.m. Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by staff #1 (S1) and granted access. S1 called the Administrator Agustine Kehinde and the reason for the visit was explained. Administrator would not be able to attend at the moment but would be arriving at a later time. Administrator designated House Manager (HA) Adebisi Ogunsajo to assist LPA in the meantime.

At 10:00 a.m. LPA and the HA toured the physical plant of the facility inside and outside, and the following was observed.

Living room: There are 2 living room areas, both were clean and properly furnished. LPA observed one (1) fire extinguisher fully charged last serviced 04/26/2024.

Kitchen: The kitchen was observed to be clean and clear of clutter. 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 all 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 04/26/2024. Dining area had an 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. Two (2) bedrooms are 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. One (1) bedroom is used for live in staff, it was locked and inaccessible to residents. (Continued on LIC809-C)
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AUTUMN HILLS RESIDENTIAL HOME, INC.
FACILITY NUMBER: 197606938
VISIT DATE: 04/29/2024
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Bathrooms: The facility has 3 bathrooms. LPA took water temperature at 10:15 a.m. from one (1) out of the three (3) bathroom's sink and temperature read 105.0 degrees F. LPA observed the bathrooms to be clean and properly supplied with toilet paper, soap, paper towels.

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 covered patio. LPA observed appropriate furniture for residents to use. There is a small shed that was locked and used to store extra facility supplies.

Administrative: LPA collected Resident Roster, LIC500 and Liability Insurance. Annual fees are current.

Resident Records: From 10:30 a.m. to 11:30. a.m. LPA reviewed resident records.

Staff Records: From 11:30 a.m to 12:00 p.m. LPA reviewed staff records.

Interviews: From 12:30 p.m. to 2:00 p.m. LPA conducted interviews with four (4) out of four (4) residents and three (3) out of four (4) staff present.

At 1:00 p.m. LPA observed Administrator test a dual smoke and carbon monoxide detector. Detectors are hardwired and interconnected to other detectors located throughout 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.

No citations issued. Exit Interview Conducted. A copy of this report provided.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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