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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601221
Report Date: 03/04/2024
Date Signed: 03/04/2024 04:00:43 PM


Document Has Been Signed on 03/04/2024 04:00 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Debra Davenport Residential ManagerTIME COMPLETED:
04:00 PM
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On 3/4/24, Licensing Program Analyst (LPA) Felisa Shirley and Troy Watson conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA was met by House Manager Debra Davenport and explained the purpose of today’s visit. The facility has a census of 4.

The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, (2) bathrooms (1) office, (1) client bathroom and (1) staff bathroom, living room, kitchen, dining area, office, patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility.

LPA Felisa and Troy and House Manager Debra Davenport walked through the kitchen and all appliances were in good working order. Medications and Knives were locked and stored an upper cabinet the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 118.9 degrees Fahrenheit. All bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly. The walk-in shower was free of mildew and mold.

LPA Felisa and Troy and Debra walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen.

LPA Shirley and Troy and Debra toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. The (2) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. (1) Resident file along with medications are current. (1) Staff file is current. The facility is in good repair. PPE's will last for 30 days plus.

An exit interview was held and a copy of the report was provided to Debra Davenport, House Manager.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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