197610091-11-23-2022-31-AS-NMAN-CMDQ5A-20221223105135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610091
Report Date: 11/23/2022
Date Signed: 11/23/2022 03:46:25 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
04/12/2021 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20210412084224

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:	11/23/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Myline Olivas, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Lack of Supervision

Licensee failed to meet resident 1 (R1)'s needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela made a subsequent visit to deliver the findings for the above noted allegations. LPA met with Administrator Myline Olivas. The purpose of the visit was discussed.

It was reported that there were was a lack of night supervision at the facility on 4/05/2021. To investigate this allegation on 4/19/2021 at 2:21pm, staff interviews were initiated. Interviews revealed that Staff #1 (S1) was tired and fell asleep while on duty. On 10/25/2022 between 3:30pm and 4:00pm, LPA reviewed a copy of the Emergency Medical Services report and confirmed what staff reported to LPA. On 4/05/2021 at 1:46am the L.A. Fire Department was called and upon their arrival at 1:51am, they were not able to get staff to open the front door. They entered through a back sliding glass door and found staff asleep.

Based on interviews and records review, there is sufficient information to support this allegation. Therefore, this allegation is SUBSTANTIATED at this time.
See 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

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-20210412084224

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: 11/23/2022

NARRATIVE

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It was alleged that Licensee failed to meet Resident #1 (R1)'s needs. To investigate this allegation on 4/19/2021 at 2:21pm, staff interviews were initiated. Staff interviews revealed that they were not aware if R1 had fallen from the bed. On 4/19/2021 between 2:40pm and 2:50pm, LPA attempted to interview R1, but was unable to because they were asleep. On 10/25/2022 between 3:30pm and 4:00pm, LPA reviewed a copy of the Emergency Medical Services report and it stated that L.A. Fire Department found R1 on the ground being assisted by R2 to use the bathroom.

Based on interviews and records review, there is sufficient information to support this allegation. Therefore, this allegation is SUBSTANTIATED at this time.

Exit interview conducted, deficiencies cited, and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20210412084224

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: 11/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/02/2022 Section Cited CCR 87415(a)	1 2 3 4 5 6 7	87415(a) Night Supervision- The following persons providing night supervision from 10pm to 6am...shall be available as indicated below to assist in caring for residents in the event of an emergency. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall submit in writing to CCLD by 12/02/2022 how they will ensure that night staff are available to provide care and supervision to all residents in care.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not ensure that night staff were avaiable to assist residents in care. Night staff were asleep and unresponsive when th fire department arrived. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 12/02/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- To have care, supervision, and services that meet their individual needs and delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall submit in writing to CCLD by 12/02/2022, how they will ensure that facility staff are competent to provide the services necessary to meed residents in care needs.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not ensure that facility staff were competent to provide the services necessary to met resident needs. A resident was on the ground and was not assisted by staff to the restroom and to bed at night time. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

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
04/12/2021 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20210412084224

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:	11/23/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Myline Olivas, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Licensee/staff failed to follow Fire Safety Requirements

Reporting Requirements

INVESTIGATION FINDINGS:

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This is an addendum to the licensing report issued on 11/23/2022. Upon review of additional information, this report is being amended. Licensing Program Analyst (LPA) Rosaura Valenzuela made a subsequent visit to deliver the findings for the above noted allegations. LPA met with Administrator Myline Olivas. The purpose of the visit was discussed.

It was reported that Licensee/staff failed to follow Fire Safety Requirements by having a double bolted lock on the front door. On 4/19/2021 at 2:21pm, staff interviews were initiated. Staff interviews revealed that the locks are standard. In addition, the front door double bolted lock is hollow. On 4/19/2021 at 2:03pm, via face-time, LPA observed the lock to be hollow. On 11/23/2022 at 2:30pm, LPA observed the door bell to be working. LPA rang the door bell and staff opened the door.
Based on interviews and observation, there is not sufficient information to support this allegation. Thus, this allegation is deemed UNSUBSTANTIATED at this time.
See 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

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-20210412084224

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: 11/23/2022

NARRATIVE

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It was reported that Licensing reporting requirements were not met. To investigate this allegation, on 10/25/2022 between 4:00pm and 4:30pm, LPA reviewed the facility's Serious Incident Reports (SIRs) file. LPA was able to verify that the facility did submit to Licensing an SIR regarding the incident that occurred on 4/05/2021.

Based on records review, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5