306000258-10-17-2022-22-AS-KSGH-CKAT72-20221017142802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000258
Report Date: 10/17/2022
Date Signed: 10/17/2022 02:28:09 PM

Document Has Been Signed on 10/17/2022 02:28 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	AUTUMN GROVE CARE HOME		FACILITY NUMBER:	306000258
ADMINISTRATOR:	O'CONNELL, PATRICIA KAY		FACILITY TYPE:	740
ADDRESS:	616 EAST GROVE AVENUE		TELEPHONE:	(714) 998-7365
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 6	DATE:	10/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Bimbo "Mack" Delos Reyes, caregiver		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/17/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by Bimbo "Mack" Delos Reyes, caregiver after explaining the purpose of the visit. At approximately 1:45pm, LPA accompanied by caregiver toured the physical plant of the facility. There are currently six (6) residents in care, four (4) of which are receiving hospice care. Residents are observed relaxing in their respective bedrooms or in the common areas. All appear clean and well taken care of. Bedrooms are all equipped with the required elements of furnishing. Physician orders for postural supports have been verified. Bathrooms are equipped with grab bars and slip mats along with hand-washing signs. An ample supply of linen is observed. Facility is observed to be clean, sanitary and free of odors in all areas inspected. Sharp instruments are kept secured in a kitchen drawer equipped with a functioning key lock. Cleaning supplies are securely stored under the kitchen sink as well as in cabinets above the laundry area. The centrally stored medication is located in multiple drawers with key locks that are all observed to be functional. LPA observed a sufficient supply of food and water present, along with an emergency supply of food and water. The fire extinguisher present is charged and has been a maintenance tag shown to be current until December 2022. The two staff members present are adequately cleared and associated in Guardian. The required training and documentation for the renewal of the Administrator certificate have been submitted ahead of the expiration date. Due to the current processing backlog, Administrator is still awaiting to receive their certificate. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AUTUMN GROVE CARE HOME	FACILITY NUMBER: 306000258
	VISIT DATE: 10/17/2022

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CONTINUED FROM FORM LIC809

LPA and caregiver toured the outside of the facility. The exterior part of the physical plant is shown to be clear of obstruction and debris. Two sheds are used for storage. Outdoor furniture and a shaded area are present in the backyard for the enjoyment of residents and visitors. The perimeter gates on both sides of the house are self-latching and can easily be opened in an evacuation. Physical plant exits are all equipped with functional sound alarms. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

LIC809 (FAS) - (06/04)

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