197610091-2-10-2022-31-AS-CHAS-CE4T9R-20220504143221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610091
Report Date: 02/10/2022
Date Signed: 02/10/2022 10:48:52 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2021 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20211229142313

FACILITY NAME:	AUTUMN ELDER CARE		FACILITY NUMBER:	197610091
ADMINISTRATOR:	OLIVAS, MYLINE		FACILITY TYPE:	740
ADDRESS:	10055 SUNNYBRAE AVE		TELEPHONE:	(747) 237-0417
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 5	DATE:	02/10/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Myline Olivas		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Sexual abuse
Lack of supervision

INVESTIGATION FINDINGS:

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At approzimately 10:00 AM on 02/10/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted a subsequent complaint investigation. LPA met with Administrator and disclosed the reason for the visit.

Sexual Abuse
Regarding the allegation of sexual abuse, it was alleged Resident #1 (R1) tried to molest Resident #2 (R2) on the evening of 12/27/2021. To investigate the allegation, LPA interviewed staff and residents during an initial complaint investigation on 12/30/21. Based on interviews, R1 often wandered in the facility to the point that the facility installed motion detectors in the hallways. At R2’s request, the motion detectors were turned off and R2’s door was open. R1 entered R2’s room and touched R2’s hand, though the touching was not sexual. Based on information obtained, there was not enough evidence to support the allegation of sexual abuse, so the allegation is deemed unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20211229142313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/10/2022

NARRATIVE

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Lack of supervision

Regarding the allegation of lack of supervision, it was alleged staff took 3 to 4 minutes to remove R1 from R2’s room. To investigate the allegation, LPA interviewed staff and residents during an initial complaint investigation on 12/30/21. Based on interviews, 2 staff responded when R2 yelled for help. One staff stayed with R2 while the other staff member removed R1 from the room. Based on the information obtained, the allegation of lack of supervision is deemed unsubstantiated.

LPA conducted exit interview and issued report.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC9099 (FAS) - (06/04)

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