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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604524
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:45:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:AUTUMN VILLAS ON HONORS DRIVE, LLCFACILITY NUMBER:
374604524
ADMINISTRATOR:KANAN, KARENFACILITY TYPE:
740
ADDRESS:5874 HONORS DRIVETELEPHONE:
(858) 750-2021
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Karen KananTIME COMPLETED:
12:12 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), Natasha Persaud conducted a Prelicensing inspection. A Change of Ownership application to operate a Residential Care Facility for the Elderly was received on 11/12/21. The facility was approved to care for six (6) elderly residents; five (5) Non-Ambulatory, and one (1) Bedridden. LPA was greeted and allowed entry into the facility by Licensee, Karen Kanan.

Structure- The facility is a single story structure with 6 bedrooms, and 3 bathrooms. There is an outdoor covered area for resident use. No bodies of water were observed.
Bedrooms Residents- Rooms #1-#6 may be used for Non-Ambulatory and bedridden; Only one (1) bedridden at a time.
Bedrooms Staff- There is no staff bedroom.
Bathrooms- All bathrooms have a working toilet, sink, grab bars and tub/showers with non-skid mats.
Linens & Hygiene Supplies- Adequate supply.
Emergency Phone Numbers, Exit Plan and Required Postings- Posted.
Smoke Detectors and Carbon Monoxide Detectors- Interconnected and hardwired.
Appliances- Stove burners, oven, microwave, washer, and dryer working.
Toxins- Stored in a locked cabinet.
Water Temperature- Measured at 118 degrees F.
Medications- Centrally stored and locked in a cabinet
First-Aid Kit- Stored in garage.
Resident & Staff Files- Located in a locked cabinet.
Activities- Adequate supplies. The facility has board games, and materials for the resident's use.
Fire clearance- Approved on 12/23/21.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: AUTUMN VILLAS ON HONORS DRIVE, LLC
FACILITY NUMBER: 374604524
VISIT DATE: 02/04/2022
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
Component III- Conducted at the Pre-Licensing visit. Information provided about how to operate the facility within substantial compliance.

All items reviewed during the visit are in compliance. Pre-Licensing is complete and this facility has no deficiencies. Facility appears to be ready for licensure pending final review. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Licensee, Karen Kanan whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2