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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005337
Report Date: 07/12/2021
Date Signed: 07/12/2021 04:29:23 PM

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 HOUSEFACILITY NUMBER:
306005337
ADMINISTRATOR:BARRIOS, PEDROFACILITY TYPE:
740
ADDRESS:5729 E SAN JUAN DRIVETELEPHONE:
(714) 321-7883
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 3DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrators Pedro Barrios and Alex BarriosTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility and temperature checked by Staff and explained the reason for the visit.

During the visit LPA toured the facility with Caregiver. Administrators Pedro Barrios and Alex Barrios arrived during visit. Facility is a 6 bedroom and 3 bathroom single story home. There are 3 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring December 4, 2022. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, paper towels and hand sanitizer. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room and bedrooms watching TV. Facility has working smoke detectors. Facility has 1 fire extinguisher which is fully charged. Facility has supply of PPE. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. Clients emergency contact information and Physicians reports are current. Facility has a designated visitation area.

No deficiencies noted during todays visit. An exit interview was conducted with Administrators Pedro Barrios and Alex Barrios and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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