374604524-2-10-2025-08-AS-AGOH-DDRS3D-20250210123056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604524
Report Date: 02/10/2025
Date Signed: 02/10/2025 12:31:07 PM

Document Has Been Signed on 02/10/2025 12:31 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	AUTUMN VILLAS ON HONORS DRIVE, LLC		FACILITY NUMBER:	374604524
ADMINISTRATOR/ DIRECTOR:	KANAN, KAREN		FACILITY TYPE:	740
ADDRESS:	5874 HONORS DRIVE		TELEPHONE:	(858) 750-2021
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY: 6		CENSUS: 6	DATE:	02/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Asst. Administrator Meredith Pritchard-Malo		TIME VISIT/ INSPECTION COMPLETED:	12:30 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) Arian Golbakhsh conducted an unannounced, Required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Danielle Thurman. The facility's license shows a maximum capacity of six (6) non-ambulatory residents age sixty (60) or above. The facility is approved for one (1) bedridden resident, who must reside in room number three (3). During today’s inspection there were six (6) residents in care. LPA and caregiver Dillan Ena toured the interior and exterior of the facility and inspected each room. Assistant Administrator Meredith Pritchard-Malo arrived later during the visit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink 1 read at 105F, bathroom 2 read at 114F, and the kitchen tap read at 111F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. [Continued on LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AUTUMN VILLAS ON HONORS DRIVE, LLC	FACILITY NUMBER: 374604524
	VISIT DATE: 02/10/2025

NARRATIVE

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[Continued from LIC 809]

No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per caregiver Dillan, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed two (2) staff and zero (0) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, aside from staff training of fire drills. Confidential records were stored in locked areas.

A deficiency was cited during the inspection for the lack of fire drills conducted as required. An exit interview was conducted with Assistant Administrator Pritchard-Malo to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/10/2025 12:31 PM - It Cannot Be Edited

Created By: Arian Golbakhsh On 02/10/2025 at 12:11 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AUTUMN VILLAS ON HONORS DRIVE, LLC	FACILITY NUMBER: 374604524
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review and interviews, the licensee did not comply with the section cited above in conducting staff fire drills at least quarterly, which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will send LPA a copy of fire drill training conducted for self and staff by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jennifer Lott

LICENSING EVALUATOR NAME:

Arian Golbakhsh

LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC809 (FAS) - (06/04)

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