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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547203298
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:14:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2022 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220414095227
FACILITY NAME:AUTUMN OAKSFACILITY NUMBER:
547203298
ADMINISTRATOR:ONG, ANTONIO G.FACILITY TYPE:
740
ADDRESS:848 N. JAYE STREETTELEPHONE:
(559) 784-4144
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:44CENSUS: 23DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Lisa OngTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident was neglected while in care resulting in resident falling and sustaining a fracture
INVESTIGATION FINDINGS:
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During the investigation, the Department reviewed R1’s records and interviewed staff. Based on interviews and records review, R1 had several ground level falls on 4/9/22 however staff did not seek medical attention until the last fall when R1 fell face first into the nightstand and was observed to be wedged between the nightstand and the bed. Staff called emergency medical services and R1 was transferred to the hospital where R1 was admitted and diagnosed in part with a left proximal humeral fracture. R1 remained in the hospital until discharged on 4/15/22. The preponderance of evidence standard has been met therefore the allegation that resident was neglected while in care resulting in resident falling and sustaining a fracture is substantiated.

Deficiency for violation of Title 22, Section 87468.2(a)(4) cited in the attached 9099D.

An immediate civil penalty of $500 is assessed and the issuance of additional civil penalties is currently under review. The details of the additional civil penalties will be outlined in a future report to the facility if needed.

Appeal rights provided. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20220414095227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AUTUMN OAKS
FACILITY NUMBER: 547203298
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2022
Section Cited
CCR
87468.2(a)(4)
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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs
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By tomorrow’s due date, Licensee will submit a plan, detailing the steps that will be taken to ensure staff provide care and supervision consistent with resident needs and seek timely medical attention
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** This requirement was not met as evidenced by R1 falling several times on 4/9/22 and staff not seeking medical attention for R1 until the last fall that resulted in R1 sustaining a fracture.





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when observations reveal unmet needs. Plan shall include a date by which all staff will be trained on this subject within 15 days of today’s date.

CIVIL PENALTY ASSESSED
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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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2022 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220414095227

FACILITY NAME:AUTUMN OAKSFACILITY NUMBER:
547203298
ADMINISTRATOR:ONG, ANTONIO G.FACILITY TYPE:
740
ADDRESS:848 N. JAYE STREETTELEPHONE:
(559) 784-4144
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:44CENSUS: 23DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Lisa OngTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Multiple residents experience falls at facility
INVESTIGATION FINDINGS:
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During the investigation, the Department reviewed records and interviewed staff. The allegation that multiple residents experience falls at the facility may have happened and/or is valid however there was not a preponderance of evidence to prove or disprove the allegation occurred therefore the complaint is unsubstantiated.

Exit interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2022 and conducted by Evaluator Melinda Medina
COMPLAINT CONTROL NUMBER: 24-AS-20220414095227

FACILITY NAME:AUTUMN OAKSFACILITY NUMBER:
547203298
ADMINISTRATOR:ONG, ANTONIO G.FACILITY TYPE:
740
ADDRESS:848 N. JAYE STREETTELEPHONE:
(559) 784-4144
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:44CENSUS: 23DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Lisa OngTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Call button/pull cord is not accessible to resident
INVESTIGATION FINDINGS:
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During the investigation, the Department reviewed records and interviewed staff. The allegation that call button/pull cord is not accessible to resident was investigated. During tour of facility this department observed pull cord in room for R1 and other resident rooms to be accessible and functioning with call light and audible sound.

This agency has investigated the complaint allegation and have found that the complaint was unfounded, therefore we have dismissed the complaint.

Exit interview conducted.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4