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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610091
Report Date: 11/10/2021
Date Signed: 11/10/2021 10:23:25 AM

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: 5DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Myline Olivas/ AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and explained the reason for the visit was to conduct an infection control visit. LPA was greeted by 2 staff members and the administrator was called and arrived at the facility a short while later. LPA's temperature was taken and LPA was asked about COVID-19 symptom questions before being allowed entry.

The facility has four bedrooms designated for resident use and one room for staff. There are also 2 bathrooms for residents and one staff bathroom in the garage. The smoke alarms and carbon monoxide detectors were tested and function properly. The fire extinguisher was last serviced on 8/20/21.

The facility is currently following their approved mitigation plan and no health and safety concerns were observed during todays visit. Exit interview conducted and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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