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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005337
Report Date: 06/30/2022
Date Signed: 06/30/2022 12:25:46 PM


Document Has Been Signed on 06/30/2022 12:25 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 HOUSEFACILITY NUMBER:
306005337
ADMINISTRATOR:BARRIOS, PEDROFACILITY TYPE:
740
ADDRESS:5729 E SAN JUAN DRIVETELEPHONE:
(714) 321-7883
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 2DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:House Manager - Alexander Barrios
Care Giver - Marleen Chavez		TIME COMPLETED:
12:43 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio and Licensing Program Manager (LPM) Sheila Santos conducted an unannounced required annual inspection focusing primarily on the Infection Control. At 8:58am LPA and LPM were greeted and granted entry by caregiver Marleen Chavez who failed to check temperature upon entry after LPA advised caregiver to do so, temperature was checked. During the visit House Manager (HM) Alex Barrios was also present and assisted LPA & LPM. As of today, there are no active COVID-19 cases in the facility as verified. LPA and LPM observed the required COVID-19 precautionary signs posted on the main entrance door and around the facility. The PUB475 "See Something, Say Something" poster was observed by the entryway . LPA observed the Administrator's Certificate for Pedro Barrios expires on December 4, 2022.

Around 9:15 AM, LPA and LPM toured the interior and exterior portions of the facility HM. The facility is a single level structure and licensed for six non-ambulatory residents. Currently, there are a total of two residents in care, of which one is under hospice care. LPA and LPM observed that facility was clean and sanitary. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilet was operational, and grab bars and non-skid floor mats were provided. Shared resident bathroom water was measured at 106.8 degrees Fahrenheit. LPA and LPM observed that facility was missing paper towels in restroom and HM provided paper towel on the spot. Upon entering resident room #2, it was observed that there was a strong, urine odor and HM stated that they have been cleaning resident #1 bedroom due to some occasional circumstances that resident #1 refuses to go to the restroom.

Continued on page 2.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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Document Has Been Signed on 06/30/2022 12:25 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: AUTUMN HOUSE
FACILITY NUMBER: 306005337

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87365(h)(2)
87365(h)(2)
Incidental Medical and Dental Care
(2) Centerally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centerally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, facility failed to keep the centrally stored medication in a safe and locked place that is not accessible to residents in care, other than employees responsible for the supervision of centrally stored medication. LPA and LPM observed a plastic box in a vacant resident room with medication, and a bottle of cough medication by the kitchen sink. This poses an immediate threat on the health and safety of the residents in care.
POC Due Date: 07/14/2022
Plan of Correction
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House Manager removed the medication box from vacant room and cough medication by the sink during the visit. Administrator will provide training to all the staff on regulations cited. Proof of training will be submitted before or on 07/14/2022 via fax at (714) 703-2868 attention to LPA De Perio.
Type B
Section Cited
CCR
87625(b)(3)
87625(b)(3)
Managed Incontinence
(3) Ensuring the continent residents are kept clean and dry and that the facility remains free of odors from incontinence.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, a urine odor was observed during the facility resident bedroom tour for resident #1. This poses the health and safety of the residents in care.
POC Due Date: 07/14/2022
Plan of Correction
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As Plan of Correction, House Manager will ensure that room is kept clean and odor free at all times. LPA will be back for a plan of correction visit after the due date.
In addition a proof of plan on how to maintain an odor free resident bedroom will be submitted to LPA De Perio on or before 07/14/2022.

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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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 HOUSE
FACILITY NUMBER: 306005337
VISIT DATE: 06/30/2022
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Facility met the minimum two day perishable and seven day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Fire extinguisher was charged and located in the kitchen. For the exterior portion, LPA and LPM observed patio furniture under shading, and the grounds were free of any hazards. There were two exit gates in the backyard, which were self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had back-up emergency food and water supply, located in the garage.

LPA and LPM observed that First Aid Kit had all the required components. The facility had an adequate amount of PPE that was located in the garage. Medication closet was observed to be locked, however, LPA and LPM observed one bottle of cough medication was accessible and located by the kitchen sink, along with a plastic box filled with medications in a vacant room (bedroom #1). Toxins and disinfectant supplies were also accessible and in the kitchen. A deficiency was issued, see LIC809D.

LPA verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with HM. LPA discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA advised HM Alex Barrios to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries attention to the assign LPA.

LPA De Perio conducted an exit interview with HM Alex Barrios and explained the findings for today's visit. LPA provided copies of LIC809, LIC809D and LIC9102 during the visit.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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