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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610091
Report Date: 11/29/2022
Date Signed: 11/29/2022 11:57:54 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/29/2022 11:57 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:
(747) 237-0417
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 6DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Myline OlivasTIME COMPLETED:
12:10 PM
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On 11/29/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with administrator Myline Olivas and the purpose of the visit was explained.

At 10:50 a.m. LPA conducted a physical tour of the facility. Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPA’s temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA Martinez observed sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps and medications are centrally stored in a locked area. Garbage can has a tight-fitting lid in the kitchen. Smoke detectors/carbon monoxide are located throughout the facility. Smoke detectors and carbon monoxide detectors were tested at 11:15 a.m. and appear to be functional. Fire extinguisher has a service date of 04/18/2022. Facility has a fire door that was tested and operational. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 72.0 F. Residents Rooms: There are five (5) bedrooms of which one is designated for live in staff. Bedroom number three and four are private rooms. Bedroom one and five are shared rooms. All the five (5) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. Bathrooms: There are two (2) bathrooms in the facility. LPA observed all bathrooms to have grab bars and non-skid mats. The hot water was tested and measured at 114.4F. Garage: Facility has an attached garage that is used for laundry and storage area. Chemicals are kept locked inside a cabinet and are inaccessible to residents in care. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water.

No deficiencies cited. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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