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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547203298
Report Date: 02/10/2025
Date Signed: 02/12/2025 11:44:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
02/07/2025 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250207121401
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: 26DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
05:37 PM
MET WITH:Lisa OngTIME COMPLETED:
06:58 PM
ALLEGATION(S):
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Staff did not ensure correct medications were dispensed to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Xiong conducted complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. LPA's observed from the investigation that facility did send wrong medications for resident R1 when resident visited family on February 3, 4 & 5. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20250207121401
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AUTUMN OAKS
FACILITY NUMBER: 547203298
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidenced by:
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Per licensee, Upon discovery of the medication error, all staff were retrained on medication administering procedures. LPA obtained training documents while at the facility therefore no further correction is necessary.
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LPA observed R2's medication was sent home with R1 when R1 went home on February 3, 4 and 5, 2025.
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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: Les Xiong
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2