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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610091
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:03:07 PM

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
09/19/2022 and conducted by Evaluator Joscelyn Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220919132917
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:
09/29/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Myline Olivas TIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents are not accorded privacy in their rooms.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/29/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced complaint investigation. Upon arrival LPA met with house manager and later met with administrator Myline Olivas. The purpose of the visit was explained.

Allegation: Residents are not accorded privacy in their rooms.

It is alleged that staff are sleeping in resident’s room or in empty rooms. To investigate this allegation LPA conducted interviews with staff, residents, and toured the facility. Interviews with five (5) out of six (6) residents stated staff do not sleep in their room and are accorded their privacy. One (1) out of six (6) resident was unable to respond to any questions asked. LPA observed five (5) bedrooms in the home of which one (1) is designated for staff use. All five (5) bedrooms were toured. Two (2) bedrooms are shared and two (2 ) bedrooms are for single use. As of today’s, visit, there are not any empty beds nor bedrooms. LPA toured the staff room and observed one staff that had a scheduled day off inside of the bedroom. Based on interviews and observation, this allegation is deemed Unsubstantiated.

No deficiency issued. Report signed and delivered. Appeal rights delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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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