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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610091
Report Date: 12/02/2022
Date Signed: 12/02/2022 04:18:04 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 CAREFACILITY NUMBER:
197610091
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:10055 SUNNYBRAE AVETELEPHONE:
(747) 237-0417
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 5DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Myline Olivas,, Administrator TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Licensee failed to obtain timely medical care for Resident 1 (R1).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela made a subsequent visit to deliver the findings for the above noted allegation. LPA met with Administrator Myline Olivas. The purpose of the visit was discussed.

It was alleged that Licensee failed to obtain timely medical care for Resident #1 (R1). To investigate this allegation on 4/19/2021 at 2:21pm, staff interviews were initiated. Staff interviews revealed that R1 was assessed after the fire department left. Staff did not assess R1 before the fire department came, due to Staff #1 (S1) being alseep. On 10/25/2022 between 3:30pm and 4:00pm, LPA reviewed a copy of the Emergency Medical Services report and it stated that R1 was found on the ground and unable to get up. Fire department assessed R1 and helped them get up back to the bed.

Based on interviews and records review, there is sufficient information to substantiate this allegation. Therefore, this allegation is being deemed SUBSTANTIATED at this time.
Deficiencies cited. Exit interview conducted and a copy of the report was issued.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
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 2
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: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2022
Section Cited
CCR
87465(g)
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87465(g)- Incidental Medical and Dental Care
The Licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident's health including, but not limited to, an apparent life-threatening medical crisis...
This requirement was not met as evidenced by:
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The licensee shall submit in writing to CCLD by 12/09/2022 how they will ensure that all residents in care are provided timely medical care when a medical crisis arises.
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Based on record review and interviews, the licensee failed to call 911 before R2 called to ask for assistance for R1. Staff was asleep and unware that R1 was on the ground and needed assistance.

This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
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