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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601220
Report Date: 07/21/2022
Date Signed: 07/21/2022 04:22:55 PM

Document Has Been Signed on 07/21/2022 04:22 PM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:AUTUMN I ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601220
ADMINISTRATOR:AISHA ANDREWSFACILITY TYPE:
735
ADDRESS:2423 W. 73RD STREETTELEPHONE:
(323) 754-3906
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 6CENSUS: 6DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Debra DavenportTIME COMPLETED:
04:38 PM
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On 07/21/22, Licensing Program Analysts (LPA) Gail Johnson conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Johnson met with the House Manager Debra Davenport. LPA Johnson explained the purpose of today’s visit. The facility is licensed to operate and care for six (6) developmentally disabled adults ages (18 through 59). Four (4) of their clients may be non-ambulatory. Currently, six (6) clients reside at this facility.

Facility Structure The facility is a one-story structure located in a residential neighborhood. It consists of the following: Four (4) bedrooms for clients, two (2) bathrooms, living area, dining area, kitchen, outdoor table in a shaded covered space with four (4) chairs.

Bedrooms (Client rooms) Presently two (2) clients occupy one bedroom each, and two (2) bedrooms are shared with two (2) clients in each room. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided. Storage for client personal belongings was observed.

Physical Plant LPA Johnson toured the physical plant. There were no bodies of water or obstructions on the premises. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.2 degrees Fahrenheit.

Storage & Inaccessible Items
Storage areas for personal hygiene, medications, cleaning supplies, toxins, and sharp objects were stored, locked and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Smoke detectors and carbon monoxide detectors were operable.
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AUTUMN I ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601220
VISIT DATE: 07/21/2022
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Emergency Phone Numbers, Exit Plan, Menu, Records: Emergency numbers are posted and readily available for review.. Two (2) fire extinguishers were located in the following areas: one (1) in the kitchen, and one (1) in the hallway. Facility conducted the last fire drill 06/07/22. The living room has one (1) landline telephone available for client use, and there's one phone in the kitchen. LPA reviewed LIS to verify annual fees are current. LPA Johnson reviewed the facilities profile, personnel summary report, medical records, medications, and staff records.

During the visit, LPA Johnson observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA Johnson observed staff was wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file.


An exit interview was conducted with Debra Davenport. A copy of this report was printed and provided to Debra Davenport.

End of report

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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