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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203298
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:52:50 PM

Document Has Been Signed on 07/26/2022 02:52 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
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: 23DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lisa OngTIME COMPLETED:
02:55 PM
NARRATIVE
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On 7/26/22, Licensing Program Analysts (LPAs) M. Medina and V. Gorban conducted an unannounced Annual Required Infection Control Inspection. LPAs allowed entrance through designated entry point. Visitor sign-in book available upon entry. LPAs conducted facility tour with Licensee, Lisa Ong.

Facility toured. Most bedrooms are double occupancy, with a minimum of 6-feet between beds. All resident bedrooms observed to have pull cords next to bed, LPA observed pull cords to have functioning call light with audible sound. Residents present during today's inspection observed to be participating in bible study group, sitting in dining areas and others resting in their bedroom. Kitchen toured. LPA observed facility to have a 7-day supply of non-perishable food however not a 2-day supply of perishable food available. Medications are locked and secured, residents observed to have a 30-day supply of medication available. PPE is locked and secured and available if necessary.

Facility is equipped with a pull station and sprinkler alarm system. Smoke detectors observed to be operational during today's inspection. Fire extinguishers present with a service date of 10/4/21. Facility has monthly pest control service and provided receipts to LPA during inspection visit.

Administrator to submit updated Administrator Certificate, CPR/First Aid Card, LIC 500 Personnel Report, and LIC 610 Emergency Disaster Supply no later than August 2, 2022.

Deficiencies cited on attached 809D.

Exit interview conducted. Report signed on site and a copy provided to Licensee for facility records.

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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2022 02:52 PM - It Cannot Be Edited


Created By: Melinda Medina On 07/26/2022 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AUTUMN OAKS
FACILITY NUMBER: 547203298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
(b) The following food service requirements shall apply:
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by: LPA observed facility did not have a 2-day supply of perishable food available at time of inspection visit.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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Facility to maintain minimum food requirements per Title 22 regulations. Licensee to submit POC and receipt for food purchase 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: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


LIC809 (FAS) - (06/04)
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