197610091-10-23-2023-31-AS-LNCA-CWVQ8C-20231023115627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610091
Report Date: 10/05/2023
Date Signed: 10/23/2023 11:56:46 AM

Document Has Been Signed on 10/23/2023 11:56 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Sheila Reano & Myline Olivas		TIME COMPLETED:	03:00 PM

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At 12:15pm Licensing Program Analysts (LPAs), Leslie Ngo-Castaneda, Angela Panushkina, and Huma Rahimi conducted an unannounced annual inspection at the facility mentioned above. LPAs were greeted by the staff, Sheila Reano who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit. Physical tour was conducted with the Administrator and LPAs observed the following:

Kitchen: At approximately, 12:20pm LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a drawer and inaccessible to clients in care. Fire extinguisher in the kitchen was purchased on 08/21/2023.

Medications: At approximately, 12:35pm LPAs observed medications are centrally stored and locked in the dining room cabinet.

Bedrooms: There are four (4) bedrooms designated for clients use with sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Staff bedroom was observed to be locked and inaccessible to clients in care.

Bathrooms: At 12:45pm LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPAs observed appropriate grab bar and client's bathroom had non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Hot water temperature measured at 111°F.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area

Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AUTUMN ELDER CARE	FACILITY NUMBER: 197610091
	VISIT DATE: 10/05/2023

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appeared clean and were properly furnished. The living room has a television, comfortable furniture and the fireplace is adequately screened. No obstructions and or tripping hazards throughout the facility. Laundry is located in the attached garage that can be accessed through the living room. LPAs observed all detergents locked and inaccessible to residents in care. Extra PPE supplies and food storage was also observed.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 1:20pm they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.

Outside areas: At approximately, 1:25pm LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. There is no bodies of water. LPAs discussed the importance of maintaining the care and supervision to meet the needs of clients.

Between 2:20 to 2:50pm, LPAs reviewed records of four (4) clients and two (2) staff. Client and staff records appeared to be complete and updated.

Administrative: LPAs collected Certificate of Liability Insurance, and LIC.500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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