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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005337
Report Date: 08/01/2022
Date Signed: 08/01/2022 02:11:29 PM


Document Has Been Signed on 08/01/2022 02:11 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: 3DATE:
08/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Facility Administrator-Alex BarriosTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 06/30/2022. LPA was greeted and temperature was taken prior to being granted entry by staff on duty. LPA De Perio explained reason for visit. Facility administrator Alex Barrios met with LPA De Perio to present the needed corrections.
Currently there are a total of 3 residents in care, of which 1 is on hospice. AD Barrios also verified that as of 8/1/22, there are no active COVID cases at facility.

On 06/30/22, 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. A plastic box was observed to be in a vacant resident room with medication, and a bottle of cough medication by the kitchen sink.

*Deficiency cited under Title 22 Regulation 87365(h)(2) pertaining to Incidental Medical and Dental Care has been CLEARED. Licensee has secured noted items. Licensee has also provided proof of training with all staff along with signatures of acknowledgement to ensure medications are locked and inaccessible to residents at all time. Licensee has complied with the terms of the POC.

On 06/30/22, a urine odor was observed during the facility resident bedroom tour for resident #1.

* Deficiency cited under Title 22 Regulation 87625(b)(3) Managed Incontinence has been CLEARED. Licensee has a plan for minimizing odor in rooms and has provided proof of training with all staff along with signatures of acknowledgement. Licensee has complied with the terms of the POC.

LPA De Perio conducted an exit interview with AD Barrios and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
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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