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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530100
Report Date: 03/18/2025
Date Signed: 03/18/2025 10:40:44 AM

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
03/14/2025 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250314132248
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: 3DATE:
03/18/2025
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Raul TocolTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not ensure there was food of quality to meet the needs of residents
Staff did not store food properly
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 did not ensure there was food of quality to meet the needs of residents.
Regarding the allegation “Staff did not ensure there was food of quality to meet the needs of residents” LPA conducted interviews with S#1 pertaining to the allegation stated above S#1 informed LPA that food is not handled by caregivers and that they supply residents with the food that is purchased by the administrator. LPA conducted a food supply inspection and observed a minimal of food supply in the refrigerator. LPA conducted an inspection and did not observe facility to have a second refrigerator with overflown of food supply. Staff could not provide details regarding the dates and times that the facility restocks on food supply. LPA conducted interviews with R#1 and R#2 and both residents informed LPA that they receive just enough food.

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

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
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-20250314132248
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: 03/18/2025
NARRATIVE
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Second allegation: Staff did not store food properly. Regarding the allegation “Staff did not store food properly” LPA conducted an inspection on facilities freezer during the inspection LPA observed facility to have exposed frozen meat inside the freezer without meat being sealed or placed in sealed packaging. LPA explained to staff about food safety and the preventions of foodborne illnesses, and storage practices. Based on the interviews and evidence gathered the above allegation is Substantiated.

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, 87555 (a) & (8)(9) General Food Service Requirements, 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: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250314132248
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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2025
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements...(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidence by:
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Licensee will read over General Food Service Requirement. Licensee will restock refrigerator provide pictures along with grocery receipt to LPA. Licensee will provide at training with all staff regarding food service and food quantity. A signed acknowledgement of understanding will also be provided and emailed to LPA by POC date 3/19/2025.
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Based on observation, interviews, the licensee did not follow General Food Service requirement, and did not have enough food supply that will meet the needs of 4 out of 4 residents in care.
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Type A
03/19/2025
Section Cited
CCR
87555(8)(9)
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87555 General Food Service Requirements....(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained....(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidence by:
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Licensee will read over General Food Service Requirement. Licensee will provide at training with all staff regarding food safety and the preventions of foodborne illnesses, and storage practices. A signed acknowledgement of understanding will also be provided and emailed to LPA by POC date 3/19/2025.
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Based on observation, the licensee did not follow General Food Service requirement regarding food safety and storage practices to meet the needs for 4 out of 4 residents 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: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3