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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530100
Report Date: 03/13/2025
Date Signed: 03/13/2025 01:59:39 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
03/04/2025 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250304141325
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:
03/13/2025
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Raul TocolTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff are not providing access to a resident's records
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 are not providing access to a resident's records. Regarding the allegation stated above LPA spoke with Reporting Party who informed LPA that they have attempted to reach out to the facility on several occasions (September 2024) and have yet to receive any response regarding Resident #1 personal records. On March 13, 2025, LPA spoke to Facility Administrator Nicole Stinson who informed LPA that they received a letter pertaining to R#1, however, have not responded to the request. Based on the interviews and evidence gathered the above allegation is Substantiated.

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

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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 3
Control Number 56-AS-20250304141325
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: 03/13/2025
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, 87506 Resident Records (a)(1), 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, along with a copy of the appeal rights. to Facility Caregiver Raul Tocol
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250304141325
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: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
87506(a)(1)
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87506 Resident Records....(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.....(1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.

This requirement is not met as evidenced by:

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Licensee has agreed to read over the regulation and provide training on regulation “87506 Resident Records” Licensee will email LPA a copy of the training sign-in sheet signed and acknowledge by all staff by POC date 3/21/2025. In addition, licensee shall provide documents to R#1 representative on or before POC due date.
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Based on interviews and record review, the licensee did not follow title 22 regulation pertaining to “resident records” by not providing Resident #1 representative with records request for R#1 that was requested back in September 2024.
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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: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3