306000258-11-22-2024-22-AS-RMRT-DBA37U-20241122170031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000258
Report Date: 11/22/2024
Date Signed: 11/22/2024 05:00:42 PM

Document Has Been Signed on 11/22/2024 05:00 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	AUTUMN GROVE CARE HOME		FACILITY NUMBER:	306000258
ADMINISTRATOR/ DIRECTOR:	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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Menandro Tanuyan, Administrator Designee		TIME VISIT/ INSPECTION COMPLETED:	05:00 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	Licensing Program Analysts (LPAs) Nancy Guillen and Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPAs were greeted and granted entry by Staff #1 at 1:45 PM. During today’s visit, LPAs met with Menandro Tanuyan, Administrator Designee. The facility is a single story, five bedroom, three bathroom residential home with an approved fire clearance of six non-ambulatory residents of which four may be on hospice. The facility currently has a census of six residents in care, of which four are on hospice. During today’s visit, LPA Guillen toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperatures in two of two resident bathrooms. A third bathroom is primarily for staff. The hot water temperatures measured between 119.4 and 120 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on October 29th,2024. The facility’s last fire drill was conducted in 2023. LPAs observed the PUB 475 poster was not the 20" X 26" required size and advised staff to post the theft and loss and visiting hours in a prominent place near the entryway. LPAs inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA Guillen observed spices were past expiration dates and immediately removed them. LPA Guillen advised staff to continue to look through pantry for any additional expired items and to throw them out. LPA Ruppert observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. (Continued on LIC 809-C)

Alisa Ortiz	TELEPHONE: (714) 287-4084
RoseMarie Ruppert	TELEPHONE: 714-703-2840
	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AUTUMN GROVE CARE HOME	FACILITY NUMBER: 306000258
	VISIT DATE: 11/22/2024

NARRATIVE

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(Continued from LIC 809)

LPAs reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPAs interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPAs confirmed that administrator has an active administrator certificate which will expire on August 29th, 2026.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Menandro Tanuyan, Administrator Designee and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 9102-TV, LIC 809-D and Appeal Rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/22/2024 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AUTUMN GROVE CARE HOME	FACILITY NUMBER: 306000258
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	Staff will dispose of any expired canned items and spices immediately and to continue to check if food is within dates of expiration. Please email LPA documentation regarding the procedures for checking food expiration at rosemarie.ruppert@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Alisa Ortiz	TELEPHONE: (714) 287-4084
RoseMarie Ruppert	TELEPHONE: 714-703-2840
	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC809 (FAS) - (06/04)

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