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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610091
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:32:33 PM

Document Has Been Signed on 10/31/2024 03:32 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AUTUMN ELDER CAREFACILITY NUMBER:
197610091
ADMINISTRATOR/
DIRECTOR:		OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:10055 SUNNYBRAE AVETELEPHONE:
(818) 718-9634
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Myline Olivas, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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At 9:30 AM, Licensing Program Analysts (LPAs) Angela Panushkina and Huma Rahimi conducted an unannounced annual visit. LPAs met with the Eleonor Blass, Staff #1 (S1), who granted access to the facility and then contacted the Administrator. Administrator arrived shortly after and LPAs explained the reason for the visit.

The facility is licensed for six (6) non-ambulatory, of which one (1) may be bedridden. All bedrooms are cleared for bedridden residents. In addition, the facility has a hospice waiver approved for six (6) residents.

Kitchen: At approximately, 9:50am LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. LPAs observed two (2) prescribed (narcotic) medications stored in the kitchen refrigerator and accessible to residents. LPAs did not observe a medication box nor a lock available. Facility currently has Dementia residents in care.

Medications: At approximately, 10:00am LPAs observed medications are centrally stored and locked in a 6-drawer cabinet, by the kitchen. However, one (1) of the drawers (bottom, right) was broken and LPAs observed medications were accessible to residents in care.



Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are clean and have appropriate bedding and linens. LPAs observe a two (2) top drawers in bedroom #1 were broken. Auditory alarms were tested and observed to be operational. One (1) bedroom is designated for live-in staff and during the tour, LPAs observed a window screen was loose.

Bathrooms: At 10:25am LPAs observed two and half (2½ ) bathrooms are clean. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 126.1 and 127.2°F. LPAs observed appropriate grab bar and had non-skid mat. LPAs observed a bathroom window screen in


Continue on LIC809-C
Nichelle GillyardTELEPHONE: (818) 596-4341
Angela PanushkinaTELEPHONE: 747-230-3364
DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AUTUMN ELDER CARE
FACILITY NUMBER: 197610091
VISIT DATE: 10/31/2024
NARRATIVE
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room #5 was loose. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:30am they were tested and observed to be operational. Carbon monoxide was located by the entrance and also tested and observed to be operational.

Common Areas: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher by the kitchen and was last serviced on 08/09/2024.

Outside areas: At approximately, 11:50am LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. LPAs also observed a garden tool accessible to residents in care and old kitchen sink with old counter boards placed against the wall. LPAs requested all unnecessary items to be stored in a storage or thrown away. LPAs also discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: Laundry area is located in an attached garage and LPAs observed all detergents kept locked and inaccessible to residents. Extra food storage was also observed. LPAs also observed hospice emergency kit in refrigerator. However, the box had no lock and it was accessible to residents in care.

Between 11:55am to 1:30pm, LPAs reviewed records of five (5) residents and three (3) staff. Residents and staff records appeared to be complete and updated.

Administrative: LPAs collected Certificate of Liability Insurance and LIC500.

Deficiencies cited on LIC809-D.

Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2024 03:32 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
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: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87705(f)(2)
Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above by having two (2) narcotic medications and a hospice emergency kit box for R5 in a kitchen and garage refregirator without proper locks, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2024
Plan of Correction
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Administrator will purchase a lock with a box for refregirated medications and provide copy of the receipt and or picture by POC date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs inspection, the licensee did not comply with the section cited above. The water temperature in both bathrooms were measured between 126.1 and 127.2 degree Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2024
Plan of Correction
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Administrator will adjust the hot water temperature and keep a log for one week. Proof of log will be submitted to LPA by 11/07/24.
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: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/31/2024 03:32 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
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: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in having two (2) broken top drawers in room #1 and a broken medication bottom drawer, by the kitchen. Moreover, the yard had old/used kitchen sink with old counter boards placed against the wall, and staff room along with barthroom (in room #5) had loose window screens, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator will replace broken drawers in bedroom #1 and by the kitchen and remove old sink and boads from the yard. In addition, all window screens will be fixed/replaced/repaired. A copy of receipt/picture will be submitted to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/31/2024 03:32 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
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: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)(1,2)
Administrator Qualifications: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee failed to ensure that the Administrato had knowledge Title 22 Regulations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee/Administrator will review and follow Title 22 Regulation. A statement of understanding regarding this Section will be submited to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5