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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203298
Report Date: 12/07/2022
Date Signed: 12/13/2022 09:13:15 AM

Document Has Been Signed on 12/13/2022 09:13 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
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: DATE:
12/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Lisa OngTIME COMPLETED:
02:51 PM
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LPA, L. Xiong was at the above facility to for a case management visit. I met with licensee Lisa Ong and informed her the purpose of the visit. The facility is to fax or email the following documents for resident, R1 to licensing by Monday, December 15, 2022.


· Fall Appraisals /Needs and Service Plan from 3/23/22 to 4/9/22
· Physician Report RCFE after 5/23/18
· MD notification on resident fall from 3/23/22 to 4/9/22
· Facility assessment after the fall from 3/23/22 to 4/9/22
· Facility daily report log from 3/23/22 to 4/9/22
· Fall Incident Report from 3/23/22 to 4/9/22
· Gateway post-acute from 12/31/21 to 3/23/22
· Training provided for staff on residents’ highrisk for fall
· 2019 fall incidents/assessment and reassessment per Lisa Ong Licensee R1 fell and became a high risk for fall
· 2019 hospital records per Lisa R1 fell at a wellness center and was sent to the hospital
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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