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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601221
Report Date: 03/17/2022
Date Signed: 04/04/2022 03:42:17 PM

Document Has Been Signed on 04/04/2022 03:42 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 II ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601221
ADMINISTRATOR:AISHA ANDREWSFACILITY TYPE:
735
ADDRESS:2901 W. 154TH STREETTELEPHONE:
(310) 769-4928
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 4DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Debra Davenport SupervisorTIME COMPLETED:
03:00 PM
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On 03/16/22 Licensing Program Analyst (LPA) Jade Jordan conducted an Unannounced visit to conduct an Annual inspection with an emphasis on infection control. LPA was met by Debra Davenport Supervisor.
The Purpose of the visit was explained.

Upon entry LPA was screened for Covid-19 Symptoms, and temperature was manually taken.

The facility is family home, located on a residential street. The facility is licensed for (6) developmentally disabled adults, of which (2) can be Non-Ambulatory. All clients are Vendored through West side Regional Center.

The facility interior includes (3) client bedrooms, (2) bathrooms, living room/activity room, dining area, kitchen with washer and dryer and a detached garage used for storage. All bedrooms had the required furnishings, including 1 Bed with fitted sheet, flat sheet, comforter, 1 Chair, adequate lighting, dresser/drawer space and closet. All bathrooms are sanitary, free of mold/mildew with working toilets, faucets, and showers. Hallways, and walk ways are free of obstruction and debris.

LPA observed an ample supply of Perishable/Non Perishable items.
Sharps, Toxins, and Medication were locked and inaccessible to clients in care.


LPA reviewed 2 resident files, and 1 Mars. All Records were up to date, and retained
the required documentation, including health screenings, personal rights. .

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
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 II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601221
VISIT DATE: 03/17/2022
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LPA observed a minimum of 30 day supply of PPE's. Observed were N95's , Surgical masks, Trash Cans with lids, Hand Sanitizer, Soap, Paper Towels and disinfectant. The facility retains a minimum of 30 day supply of medications, and all emergency contact numbers are up to date.The facility has
Covid -19 positings. Facility staff sanitize through out the day. Surveillance covid 19 testing is continued, although no longer required due to vaccination status.

A Technical Advisory was given for the following area(s):

Missing Face Shield and Gowns
Cosmetic touch up paint in Bathroom #2
Community Electronic device that consumers can use for video chat.

An exit interview was conducted, and a copy of this report was provided. No citations were
issued during this visit.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC809 (FAS) - (06/04)
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