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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203298
Report Date: 10/23/2025
Date Signed: 10/24/2025 09:02:24 AM

Document Has Been Signed on 10/24/2025 09:02 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AUTUMN OAKSFACILITY NUMBER:
547203298
ADMINISTRATOR/
DIRECTOR:		ONG, ANTONIO G.FACILITY TYPE:
740
ADDRESS:848 N. JAYE STREETTELEPHONE:
(559) 784-4144
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 44CENSUS: 23DATE:
10/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lisa Ong TIME VISIT/
INSPECTION COMPLETED:
04:54 PM
NARRATIVE
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On 10/23/2025, Licensing Program Analyst (LPA) L. Xiong arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator or Licensee. The staff on duty, Ligaya Escario stated Lisa O. just left the facility. LPA called and spoke to Lisa Ong and she stated she will be back to the facility soon. After a short time, Licensee, Lisa Ong arrived and met with LPA at the facility. Upon arrival, there were two staff on duty.

The purpose of today’s visit is to issue deficiencies that were observed during a case management – Health Checks inspection conducted on 09/24/2025. During this inspection, the following deficiencies were observed:

LPA and LPM observed a broken air conditioning unit, soda machine and water dispenser in the dining area. In the kitchen area, insect killer was observed to be stored in the kitchen along with paint and plant fertilizer. The walk-in freezer was observed to be broken, Licensee is utilizing the walk-in freezer to store food that requires refrigeration. LPA and LPA observed, the facility serving food that was past the best buy date. Locked freezers and food storage were observed. Facility did not store or label food to protect the safety, acceptability and nutritive values. The pantry was observed to be in need of cleaning, evidenced by dead and live roaches and spiders throughout the pantry and on shelves holding food. Two refrigerators were observed to be broken and not in use. LPA and LPM observed unsafe food service practices while Licensee was preparing lunch.

LPA and LPM observed the air return filters to be dirty and in need of replacement. The facility has 3 bathrooms with shower areas, Licensee locked 2 bathrooms preventing residents from using them. The shower in the unlocked bathroom was not operational. LPA and LPM toured resident bedrooms. The curtains in the residents room appeared to have dead pests and pest feces on them. Blood stained bedding was observed along with bedding that had holes and was in need of replacement. In room 22, LPA and LPM observed two black-widow spiders and dead bed bugs on the walls. Bed bugs were also observed on the resident’s bedding. Linen and bedding supplies were observed, it was found that the linens were not in good condition with multiple holes. LPA and LPM observed a large hole in the wall of the laundry room.

Review of records revealed that the Licensee did not have current and complete records for both resident and staff. Interviews revealed that the Administrator has not been present at the facility due to personal circumstances. The facility was not staffed with a sufficient amount of personnel to provide the services to meet the resident’s needs. LPA and LPM were unable to review medications at this time.

Deficiencies are being cited in accordance with Title 22 regulations, Division 6 CCR on the attached 809D. Exit interview was conducted and a plan of correction was reviewed and developed with the Licensee. A copy of this report and appeal rights were provided. Report was signed by facility staff.

NAME OF LICENSING PROGRAM MANAGER: Melinda Hoffmann
NAME OF LICENSING PROGRAM ANALYST: Les Xiong
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/24/2025 09:02 AM - It Cannot Be Edited


Created By: Les Xiong On 10/23/2025 at 03:50 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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87555(a)

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87555 General Food Services Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
Evidenced by: Based on observation, the facility did not comply with this section when the Facility did not provide meals that were of a good quality and quantity to meet the resident’s needs, served food that was past the best buy date, served food from damaged containers and stored food in a broken freezer
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Per Licensee, the facility shall complete the POC by the due date.
Type A
10/31/2025
Section Cited
CCR
87555(b)(9)

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87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
Evidenced by: Based on observation, the facility did not comply with this section when the facility stored food in trash bags, did not utilize freezer safe food storage, label food in the freezer; Facility did not take safety precautions while preparing food to guard meals against pests.
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Per Licensee, the facility shall complete the correction by the POC due date.
Type A
10/31/2025
Section Cited
CCR87555(b)(26)

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87555 General Food Service Requirements
(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.
Evidenced by: Based on observation, Licensee did not meet the requirements for this section when the facility was not supplied with a one-week supply of non-perishable foods and a two day supply of perishable foods.
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Per Licensee, the facility shall complete the correction by POC due date.
Type A
10/31/2025
Section Cited
CCR
87555(b)(27)

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87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
Evidenced by: Based on observations, Licensee did not comply with this section when roaches and spiders were observed in the pantry and walk-in freezer.
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Per Licensee, the facility shall complete the correction by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melinda Hoffmann
NAME OF LICENSING PROGRAM MANAGER:
Les Xiong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/24/2025 09:02 AM - It Cannot Be Edited


Created By: Les Xiong On 10/23/2025 at 04:09 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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87555(b)(24)

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87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored.
Evidenced by: Based on observations, Licensee did not comply with this section when Insect Killer, plant fertilizer, and paint were observed to be stored in the kitchen area
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Per licensee, the facility shall complete the correction by the POC due date.
Type A
10/31/2025
Section Cited
CCR
87555(b)(29)

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(b) The following food service requirements shall apply:
(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.
Evidenced by: Based on observations, Licensee did not comply with this section when the facility had multiple broken refrigerators and the walk-in freezer was broken and being utilized as food storage area.
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Per licensee, the facility shall complete the correction by the POC due date.
Type B
10/31/2025
Section Cited
CCR87555(b)(16)

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(b) The following food service requirements shall apply:
(16) In facilities licensed for sixteen (16) to forty-nine (49) residents, one person shall be designated who has primary responsibility for food planning, preparation and service. This person shall be provided with appropriate training.
Evidenced by: Based on observation, the facility did not comply with this section when the facility did not have a person designated for food planning, preparation and service.
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Per licensee, the facility shall complete the correction by the POC due date.
Type B
10/31/2025
Section Cited
CCR
87555(b)(6)

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(b) The following food service requirements shall apply:
(6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request.

Evidenced by: Based on observation, the facility did not comply with this section when the Licensee did not utilize or follow the facility menu and would only servedfood items that were close to expiration
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Per licensee, the facility shall complete the correction by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melinda Hoffmann
NAME OF LICENSING PROGRAM MANAGER:
Les Xiong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/24/2025 09:02 AM - It Cannot Be Edited


Created By: Les Xiong On 10/23/2025 at 04:16 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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
Evidenced by: Based on observations, Licensee did not comply with this section when the Licensee was the only staff on duty and was unable to provide the services necessary to meet the needs of all residents in care.
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Per licensee, the facility complete the correction by the POC date
Type A
10/31/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors…
Evidenced by: Based on observations, Licensee did not comply with this section when multiple refrigerators and freezers were observed in the facility. When a broken air conditioning unit, broken water dispenser and broken soda machine were observed in the dining area. Multiple blinds were observed to be missing in the residents’ rooms. 2 out of 2 vent return filters were observed to be dirty and in need of replacement, the curtains in the residents’ room were dirty, covered in dead pests and pest feces, the unlocked bathroom shower was non-operational, the bathroom floors and surfaces were in need of cleaning and repair. A large hole in the wall was observed in the laundry room.
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Per licensee, the facility shall complete the correction by the POC due date.
Type B
10/31/2025
Section Cited
CCR97303(c)

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87303 Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
Evidenced by: Based on observation, the facility did not comply with this section when multiple window screens needed replacement or repair.
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Per licensee, the facility shall complete the correction by the POC due date.
Type B
10/31/2025
Section Cited
CCR
87307(a)(3)

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87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function … (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair.
Evidenced by: Based on observation, the facility did not comply with this section when the Licensee did not have a sufficient number of linens that were in good repair and when residents were utilizing bedding that was stained with blood.
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Per licensee, the facility shall complete the correction by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melinda Hoffmann
NAME OF LICENSING PROGRAM MANAGER:
Les Xiong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/24/2025 09:02 AM - It Cannot Be Edited


Created By: Les Xiong On 10/23/2025 at 04:30 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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87307(b)

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87307 Personal Accommodations and Services
(b) Toilets and bathrooms shall be conveniently located. The licensed capacity shall be established based on Section 87158, Capacity, and the following (2) At least one bathtub or shower for each ten (10) persons, which includes residents, family and live-in personnel.
Evidenced by: Based on observation, the facility did not comply with this section when the license locked 2 out of 3 bathrooms equipped with a bathtub or shower preventing residents from using it.
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Per licensee, the facility shall complete the correction by the POC due date.
Type A
10/31/2025
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
Evidenced by: Based on observation, the facility did not comply with this section when the Licensee did not accord dignity and respect in her interaction with residents in care and when Licensee threw out resident belongings without permission.
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Per licensee, the facility shall complete Personnel training by the POC due date.
Type A
10/31/2025
Section Cited
CCR87468.1(a)(2)

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
Evidenced by: Based on observation, the facility did not comply with this section when the residents in room 22 where not relocated to a room without bed bugs as recommended and when the Licensee locked the refrigerators in the facility.
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Per licensee, the facility shall complete training by POC due date.
Type B
10/31/2025
Section Cited
CCR
87506(a)

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87506 Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
Evidenced by: Based on observation, the facility did not comply with this section when the Licensee did not have a completed and current record for 22 out of 22 residents in care.
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Per kicensee, the facility shall complete correction by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melinda Hoffmann
NAME OF LICENSING PROGRAM MANAGER:
Les Xiong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/24/2025 09:02 AM - It Cannot Be Edited


Created By: Les Xiong On 10/23/2025 at 04:37 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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility …
Evidenced by: Based on observation, the facility did not comply with this section when the Administrator was not present a sufficient amount of hours to run the facility.
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Per licensee, facility shall complete the correction by the POC due date.
Type B
10/31/2025
Section Cited
CCR
87412(a)

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87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
Evidenced by: Based on observation, the facility did not comply with this section when the Licensee did not have a completed and current record for all staff employed at the facility.


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Per licensee, facility shall complete the correction by the POC due date.

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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.
Melinda Hoffmann
NAME OF LICENSING PROGRAM MANAGER:
Les Xiong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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