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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600141
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:32:56 PM


Document Has Been Signed on 05/23/2024 03:32 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:AUTUMN GLOWFACILITY NUMBER:
385600141
ADMINISTRATOR:JAMES WONGFACILITY TYPE:
740
ADDRESS:654 GROVE STREETTELEPHONE:
(415) 934-1622
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:15CENSUS: 14DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Yongchuan RuanTIME COMPLETED:
04:00 PM
NARRATIVE
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On 5/23/24, LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with the House Supervisor Yongchuan Ruan, LPA explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas, and kitchen area. LPA observed some residents were at the dining area eating. While touring the facility it was observed that the temperature was at 69deg F. Hot water was also tested in the resident apartments and the temperature was 110 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Facility has a sprinkler system. Resident bedrooms and bathrooms were observed to be in good repair. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Chemicals & sharps are locked.

Four resident records and four staff records were reviewed. Three out of four resident records does not have an updated LIC602 (Physicians Report). Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Facility doesn't have an evacuation chair in the stairwell.

LPA requested the following documents: LIC308, Liability Insurance, Copy of Administrator Certificate, Control of Property, LIC610.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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 05/23/2024 03:32 PM - 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: AUTUMN GLOW
FACILITY NUMBER: 385600141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 resident files reviewed doesn't have an upadated annual assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Licensee to submit a plan to ensure that residents with dementia has an updated assessment. Licensee to submit plan by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/23/2024 03:32 PM - 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: AUTUMN GLOW
FACILITY NUMBER: 385600141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having an evacuation chair in the stairwell in case of emergency which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee to submit a plan to provide an evacuation chair in the stairwell. Licensee to submit photo of evacuation chair placement in the stairwell once done.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3