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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604524
Report Date: 01/29/2024
Date Signed: 01/29/2024 11:32:35 AM


Document Has Been Signed on 01/29/2024 11:32 AM - 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, LLCFACILITY NUMBER:
374604524
ADMINISTRATOR:KANAN, KARENFACILITY TYPE:
740
ADDRESS:5874 HONORS DRIVETELEPHONE:
(858) 750-2021
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 6DATE:
01/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Administrator's Assistant Meredith Pritchardmalo and Caregiver Danielle ThurmanTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management-Annual Contnuation visit. The LPA introduced himself and disclosed the purpose of the visit with Caregiver Danielle Thurman. Administrator's Assistant Meredith Pritchardmalo arrived during the visit and assisted the LPA. The facility was licensed for a capacity of six (6) non-ambulatory residents, with one being able to be bedridden in room # 3.

During the Annual visits, the LPA, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and resident activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, and stored in locked areas.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide , and facility telephone were operational. A fire extinguisher and first aid kit were readily accessible. Required licensing postings were observed in visible areas of the facility.

The LPA interviewed staff and reviewed multiple staff and client records/files. Deficiencies were cited in an LIC 809D, and a plan of correction was jointly formulated with Pritchardmalo.

An exit interview was conducted with Pritchardmalo, to whom a copy of this report, LIC 809D, LIC 811, and Applicant/ Licensee Rights (LIC 9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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 01/29/2024 11:32 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by:
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Administrator's assistant agreed to submit a completed Physician's Report for R5 to the LPA, by 2/9/24.
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Based on review of records, the Licensee did not ensure resident (R5) had annual medical assessment, which posed a health, safety, and personal rights risk to 1 of 6 residents in care.
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Type B
01/29/2024
Section Cited
CCR87411(c)(1)

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87411 Personnel Requirements - General (c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This was not met as evidenced by:
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Administrator's Assistant agreed to submit proof of1st aid training for S2, S3, and S4, by 2/9/24.
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Based on review of records, the Licensee did not ensure staff (S2,S3, and S4) had 1st aid training, which posed a potential health, safety, and personal rights risk to 6 of 6 residents in care.
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On a continuation annual visit, the LPA confirmed S2 and S3 had recieved 1st Aid training.
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: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/29/2024 11:32 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2024
Section Cited
CCR
87411(f)

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87411 Personnel Requirements-General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement was not met as evidenced by:
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Administrator's Assistant agreed to obtain health screenings for staff (S1,S2,S3, and S4), and submit proof to the Department, by 2/9/24.
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Based review of records, the Licensee did not ensure staff (S1,S2,S3, and S4) had a health screening, which posed a health, safety, and personal rights risk to 6 of 6 persons 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3