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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601221
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:52:09 PM

Document Has Been Signed on 03/07/2023 04:52 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
EL SEGUNDO, 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:
3107694928
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 4DATE:
03/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Brenda Davenport - House ManagerTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual Required visit. LPA Leon informed Debra Davenport, House Manager, of the purpose for today's visit. LPA Leon reviewed the physical plant, medications, food service, clients and staff records, consumer IPPs, and first aid certificates, verified that the administrator is present at the property 20+ hours per week. LPA Leon verified all current staff fingerprint cleared/associated to the facility, noted one Direct Support was not associated. The facility annual fees are current. There are currently four (4) Westside Regional Center (WRC) consumers in placement.

The facility is a single story, 3 bedrooms, 2 bathrooms home located in a residential neighborhood.
The facility has a living room, dining room, kitchen, laundry room in the detached garage, shaded area, indoor/outdoor activity areas.

Bedrooms #1-3 are designated as client bedrooms. Bedroom number three (3) is the only shared room.

Documents are posted as mandated. Bedrooms contain the furniture mandated. Bathrooms are clean and operational yet outside of Title 22 regulations. Bathroom #2 was measured at 152.2 F, first aid kit is fully stocked, smoke detectors were in compliance, medications cabinet / Sharps found unlocked and records need upkeep. Perishable food was enough, but needs a fresh supply of perishable and nonperishable food, hot water temperature above Title 22 regulations as noted above, adequate linen supply, hazardous cleaning solutions are inaccessible to clients, yard was free of debris/hazards.
Administrator certificate is current, expires 09/09/24.

During this inspection there were five (5) deficiencies noted, see LIC809-D.

An exit interview was held and a copy of the report and appeal rights, were provided to Debra Davenport, House Manager.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 03/07/2023 04:52 PM - It Cannot Be Edited


Created By: Mario Leon On 03/07/2023 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AUTUMN II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and measurement, the licensee did not comply with the section cited above in having water source at 152.2 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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House Manager and LPA have agreed that on or prior to the POC due date, facility will submit media evidence (video) via email to LPA at Mario.Leon@DSS.CA.GOV.
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on , the licensee did not comply with the section cited above in having one staff member (Catherine Ikpa - DSP1) unassociated with the facilityd which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2023
Plan of Correction
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House Manager and LPA have agreed that on or prior to the POC due date, this facility will associate DSP1 prior to having DSP1 back working at the facility.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/07/2023 04:52 PM - It Cannot Be Edited


Created By: Mario Leon On 03/07/2023 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AUTUMN II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in having a broken window panel showing a sharp edge located at the dining room, vieiwing the front yard, missing grab bar in shower of bathroom number two (2) and cabinet door below the sink located in bathroom number two (2) missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2023
Plan of Correction
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House Manager and LPA have agreed that on, or prior to, the POC due date, facility will submit media evidence (photo/video) via email to LPA at Mario.Leon@DSS.CA.GOV.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/07/2023 04:52 PM - It Cannot Be Edited


Created By: Mario Leon On 03/07/2023 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AUTUMN II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
80075(k) - Health-Related Services

This requirement is not met as evidenced by:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above in having a medicine cabinet which stores medications and sharp objects having been found to be unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2023
Plan of Correction
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House Manager and LPA have agreed that facility will submit media evidence (video) on, or prior to, the POC due date of a new working lock cylinder has replaced the current inoperable lock cylinder
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/07/2023 04:52 PM - It Cannot Be Edited


Created By: Mario Leon On 03/07/2023 at 04:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AUTUMN II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85165

85165 - Emergency Intervention Staff Training

(f) The administrator who will approve the continued use of a manual restraint or seclusion shall complete additional training which shall include the following:
(7) Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA , the licensee did not comply with the section cited above in having multiple certifications out of date, specifically First-Aid / CPR, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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House manager and LPA have agreed that current certification related to the above mentioned section will be updated on, or prior to, the POC due date and will be provided to CCLD via Fax at 323.981.1781 and will also update their personnel record folder located at the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
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