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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610091
Report Date: 06/21/2024
Date Signed: 06/21/2024 10:55:46 AM


Document Has Been Signed on 06/21/2024 10:55 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, 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:
(818) 718-9634
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 4DATE:
06/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 PM
MET WITH:Pamela Bernardo, Designee TIME COMPLETED:
11:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240513103627. LPA met with the Designee and explained the reason for the visit.

On 05/13/24, the Regional Office (RO) received a complaint and on 05/16/24, LPA conducted an initial complaint visit. After the final report was delivered, an Informal Meeting was conducted with the Administrator on 05/29/24 to discuss the deficiencies, and it was determined that an additional deficiency will be issued.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC809-D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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 06/21/2024 10:55 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: AUTUMN ELDER CARE
FACILITY NUMBER: 197610091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
HSC
1569.74(b)(6)

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(b) Any policy established pursuant to subdivision (a) shall meet all of the following conditions: (6) Facility staff are prohibited, on behalf of any resident... ...from being the legally recognized surrogate decision maker.
This requirement is not met as evidenced by:
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Administrator agreed to complete a written statement of understanding on how the facility will follow section 1569.74(b)(6). Statement must be submitted to LPA by POC date
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Based on interviews, licensee did not comply with the section cited above by failing to communicate with R1 regarding changes in level of care and made a decision on R1's behaf by not accepting R1 back or potentially transferring R1 to her other facility/location, which poses/posed a potential health and safety risk 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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