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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530100
Report Date: 12/04/2024
Date Signed: 12/04/2024 02:21:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241008134922
FACILITY NAME:AUTUMN BLISS HOMEFACILITY NUMBER:
365530100
ADMINISTRATOR:STINSON, NICOLEFACILITY TYPE:
740
ADDRESS:17885 ATHOL STTELEPHONE:
(909) 452-7417
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 4DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Raul Tocol-CaregiverTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff allowed resident to be exposed to others while being changed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Raul Tocol and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Staff allowed resident to be exposed to others while being changed. Regarding the allegation “Staff allowed resident to be exposed to others while being changed” LPA conducted an interview with Facility Administrator who self-admitted to the allegation stated above. Administrator informed LPA that a meeting was held with staff regarding the utilization of phones/and or receiving video calls while residents are being dressed and/or bathed. In addition, Facility Administrator informed LPA that staff acknowledge the violation and will no longer utilize phones when residents are being dressed/and or bathed. Based on the evidence gathered during the investigation, the above allegations are Substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20241008134922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AUTUMN BLISS HOME
FACILITY NUMBER: 365530100
VISIT DATE: 12/04/2024
NARRATIVE
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Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personal Rights of Residents in All Facilities 87468.1 (a) (3), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Raul Tocol at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241008134922

FACILITY NAME:AUTUMN BLISS HOMEFACILITY NUMBER:
365530100
ADMINISTRATOR:STINSON, NICOLEFACILITY TYPE:
740
ADDRESS:17885 ATHOL STTELEPHONE:
(909) 452-7417
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 4DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Raul Tocol-CaregiverTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not ensure residents are kept in clean dry clothing at all times
Staff do not ensure residents are spoken to in an appropriate manner
Staff did not ensure resident was provided assistance with use of oxygen equipment
Staff does not ensure food is of good quality and quantity for residents in care
Staff handle residents in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Raul Tocol and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Staff do not ensure residents are kept in clean dry clothing at all times. Regarding the allegation “Staff do not ensure residents are kept in clean dry clothing at all times” LPA conducted interviews with four residents regarding the allegation stated above and three out of four residents stated that facility staff are meeting their basic care needs and ensure that their laundry gets washed. In addition, three residents informed LPA that their clothes are always cleaned and washed by staff. LPA conducted interviews with staff regarding the allegation stated above Staff #1 and Staff #2 informed LPA that laundry is done daily for each resident. Furthermore S#1 and S#2 informed LPA that residents linens get washed twice a week and up to three times a week depending on if linens get soiled.

Second allegation: Staff do not ensure residents are spoken to in an appropriate manner.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20241008134922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AUTUMN BLISS HOME
FACILITY NUMBER: 365530100
VISIT DATE: 12/04/2024
NARRATIVE
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Regarding the allegation “Staff do not ensure residents are spoken to in an appropriate manner” LPA conducted interviews with four residents and three out of four residents denied staff speaking to residents in an appropriate manner. In addition, three out of four residents denied witnessing staff speak to residents in an appropriate manner. Residents informed LPA that they have no concerns and feel safe at the facility. LPA conducted interviews with staff regarding the allegation stated above and three out of three staff denied speaking to residents in an appropriate manner.

Third allegation: Staff did not ensure resident was provided assistance with use of oxygen equipment. Regarding the allegation “Staff did not ensure resident was provided assistance with use of oxygen equipment” LPA conducted an interview with Facility Administrator who informed LPA that Resident#1 was recently admitted at the facility on 10/4/2024. Administrator informed LPA that R#1 oxygen was ordered and delivered by R#1 hospice agency two days later on 10/6/2024 oxygen was delivered for R#1.

Fourth allegation: Staff does not ensure food is of good quality and quantity for residents in care. Regarding the allegation “staff does not ensure food is of good quality and quantity for residents in care” LPA conducted an inspection on facilities food supply. During the inspection LPA discovered that the facility had adequate amount of food supply to meet resident needs. In addition, LPA observed that all food including canned goods sustained current shelf life.

Fifth allegation: Staff handle residents in a rough manner. Regarding the allegation “Staff handle residents in a rough manner” LPA conducted interview with residents, three out of four residents denied being handled in a rough manner by staff. In addition, R#2, R#3, and R#4, denied witnessing staff handling R#1 in a rough manner. LPA conducted interviews with staff regarding the allegation stated above and three staff denied handling R#1 on a rough manner. In addition, S#1, S#2, and S#3 also denied witnessing staff handling R#1 on a rough manner. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.

Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Raul Tocol at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20241008134922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AUTUMN BLISS HOME
FACILITY NUMBER: 365530100
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
HSC
87468.1(a)(3)
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Personal Rights of Residents in All Facilities... (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:... (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of punitive nature, including but not limited to: interference with the daily living function, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning.
This requirement is not met as evidence by:
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Licensee has agreed to read over the "Personal Rights of Residents in All Facilities" regulation and provide training to all staff regarding the violation of resident’s rights. Licensee will email LPA Guerrero a copy of the training. Licensee will ensure that training is signed and dated by all staff by POC date of 12/13/2024.
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Based on interviews, the licensee did not ensure staff followed Personal Rights regulation for 1 out of 3 residents which, poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5