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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610091
Report Date: 06/12/2025
Date Signed: 06/12/2025 07:55:24 PM

Substantiated


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
06/05/2025 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20250605153846
FACILITY NAME:AUTUMN ELDER CAREFACILITY NUMBER:
197610091
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:10055 SUNNYBRAE AVETELEPHONE:
(818) 718-9634
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 3DATE:
06/12/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Valiant Po, Staff TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not provide proper notice of increase in rate.
INVESTIGATION FINDINGS:
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At 09:15am, Licensing Program Analyst (LPA), Angela Panushkina and Licensing Program Manager (LPM), Nichelle Gillyard conducted an unannounced visit in response to the above-mentioned allegation. LPA/LPM met with the Staff #1 (S1), who granted access to the facility. Administrator was contacted and the reason for the visit was explained.

At 09:20am, LPA/LPM requested resident and staff roster. At 9:25am requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, Resident Daily Log, relevant to the investigation. At approximately 9:30am, LPA/LPM conducted a physical plant tour, to ensure health and safety of the residents are protected. Between
9:50am – 11:00am, LPA/LPM interviewed one (1) staff, three (3) residents and one (1) witness.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20250605153846
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: 06/12/2025
NARRATIVE
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Allegation: Staff did not provide proper notice of increase in rate.

It was alleged that the facility provided a rate increase notice for R1 due to the high level of care required by the staff. To investigate this allegation LPA/LPM conducted an interview with S1 and were informed that R1 was admitted to this facility on 04/18/25. R1 required full assistance with the Activities of Daily Living (ADLs). LPA/LPM were also informed that R1 would call at 2:00am and request to pull the pillow up or ask for an ice among other basic tasks. S1 provided copies of R1’s daily notes. LPA/LPM conducted review or R1’s daily notes and observed that R1’s level of care remained the same from April 20th, 2025 to May 30th, 2025. Additionally, LPA/LPA conducted review of R1’s Preplacement Appraisal and Appraisal Needs and Service plan (dated on 04/18/25) and Physician’s Report (dated on 04/18/25) and observed that both documents indicated that R1 had various health, mental and physical condition. LPA/LPM asked S1 about major change in R1’s health condition between April 18th, 2025, and May 31st, 2025, and there was no change in health or medical condition.Review of R1’s level of care appraisal letter submitted by the licensee (on 05/12/2025) did not specify and changes in R1’s health condition but expressed assistance with basic need and requests which include but not limited to asking for ice,straighten bed and pillow during late hours. This is not sufficient reason to increase the rent. No updated reappraisal was observed to support the letter. Therefore, the rate increase was invalid and improperly requested. Lastly, according to Health and Safety Code 1569.55, any increase in rates, require a (60 days) written notice, and the notice must include the reason for the increase, as well as a detailed description of the additional cost. Based on the interviews and record reviews, this allegation is Substantiated.

Deficiency cited on LIC9099-D



Exit interview conducted, appeal rights explained and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250605153846
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2025
Section Cited
HSC
1569.655(a)
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Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase... (a) If a licensee of a residential care facility... setting forth the amount of the increase and the reason... including a description of the additional costs
This requirement is not met as evidenced by:
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POC is cleared during today's visit. LPA/LPM were informed that R1 moved out from the facility on 05/31/25
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Based on interviews and record reviews, licensee did not comply with the section cited above, by issuing improper rate increas to R1, which poses/posed a potential health and safety risk to persons in care.
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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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/05/2025 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20250605153846

FACILITY NAME:AUTUMN ELDER CAREFACILITY NUMBER:
197610091
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:10055 SUNNYBRAE AVETELEPHONE:
(818) 718-9634
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 3DATE:
06/12/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Valiant Po, Staff TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff inappropriately speaks to resident.
INVESTIGATION FINDINGS:
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At 09:15am, Licensing Program Analyst (LPA), Angela Panushkina and Licensing Program Manager (LPM), Nichelle Gillyard conducted an unannounced visit in response to the above-mentioned allegation. LPA/LPM met with the Staff #1 (S1), who granted access to the facility. Administrator was contacted and the reason for the visit was explained.

At 09:20am, LPA/LPM requested resident and staff roster. At 9:25am requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, Resident Daily Log, relevant to the investigation. At approximately 9:30am, LPA/LPM conducted a physical plant tour, to ensure health and safety of the residents are protected. Between
9:50am – 11:00am, LPA/LPM interviewed one (1) staff, three (3) residents and one (1) witness.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250605153846
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: 06/12/2025
NARRATIVE
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Allegation: Staff inappropriately speaks to resident.

It was alleged that Staff #1 (S1) inappropriately spoke to R1. To investigate this allegation LPA/LPM conducted an interview with S1, who denied the above allegation and informed LPA/LPM that he/she always assisted R1 and other residents with dignity and respect. In addition, three (3) residents interviewed expressed no concerns regarding this allegation. Interview also revealed that they have not witnessed nor heard staff inappropriately speak to R1 and or other residents. Lastly, interview with the witness revealed that the facility staff is very professional and he/she never witnessed S1 inappropriately speak to residents. Based on interviews there is insufficient pertinent information to support the allegation. Therefore, the allegation is Unsubstantiated, at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5