<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530100
Report Date: 08/30/2024
Date Signed: 08/30/2024 01:46:07 PM

Document Has Been Signed on 08/30/2024 01:46 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AUTUMN BLISS HOMEFACILITY NUMBER:
365530100
ADMINISTRATOR/
DIRECTOR:		STINSON, NICOLEFACILITY TYPE:
740
ADDRESS:17885 ATHOL STTELEPHONE:
(909) 452-7417
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 3DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:31 PM
MET WITH:Raul Tocol-CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Caregiver Raul Tocol and was granted entry to the facility. At the time of the visit there was one (1) staff present, and three (3) residents present. The facility is a four (4) bedroom, two (2), bathroom home, with a kitchen/dining area, living room, with an attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (3). LPA was accompanied by Facility Caregiver Raul Tocol, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 110.6 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside medication closet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Paola Guerrero On 08/30/2024 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above of not having personnel files available for licensing upon request, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
1
2
3
4
Licensee has agreed to read over the Personnel Records regulation and provide record training to all staff. Licensee will provide proof of training and email POC to LPA Guerrero by due date 9/20/2024.
Type B
Section Cited
CCR
87506(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above of not having residentl files available for licensing upon request, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
1
2
3
4
Licensee has agreed to read over the Resident Records regulation and provide record training to all staff. Licensee will provide proof of training and email POC to LPA Guerrero by due date 9/20/2024.
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:Efren Malagon
LICENSING EVALUATOR NAME:Paola Guerrero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Record Review: LPA was not able to review any staff files during today's visit.

Deficiencies were issued for inaccessible files, deficiency pose a potential health and safety risk to residents in care.



An exit interview was conducted where this report, LIC 809D, and appeal rights was discussed and copies were provided to Direct Support Staff Cynthia Santos at the conclusion of the inspection.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3