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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610091
Report Date: 11/13/2020
Date Signed: 11/13/2020 12:45:23 PM

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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AUTUMN ELDER CAREFACILITY NUMBER:
197610091
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:10055 SUNNYBRAE AVETELEPHONE:
(747) 237-0417
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 6DATE:
11/13/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Myline OlivasTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Wendell Smith conducted a virtual prelicensing through face-time with applicant Myline Olivas. Facility is fire cleared for five non-ambulatory and one bedridden. Facility is currently occupied and has six residents. LPA was given a tour of the physical plant. Facility has five bedrooms. Two bedrooms are private bedrooms while two bedrooms are shared rooms. One bedroom is designated for staff. There are two bathrooms for residents and a half bathroom that is designated for staff. LPA observed all bedrooms to be appropriately furnished. All resident bathrooms have grab bars and non skid material. LPA was given a tour of the living room of the facility which LPA observed to be furnished appropriately. LPA checked the kitchen area for the ability to prepare and store food. LPA observed there to be a sufficient amount of perishable and non perishable food. LPA observed knives, sharp objects, and cleaning supplies to be locked away and inaccessible to residents. LPA observed medication to be locked away in an area near the kitchen. During the visit LPA observed caregivers to be wearing face mask. LPA observed the backyard of the facility to be free of clutter and debris. There is a nice patio area that was observed for residents to sit and enjoy outside activities. No concerns were noted during the visit. Exit Interview conducted. LPA will notify case carrying LPA of this report and report to Central Application Unit.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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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