565800841-1-13-2025-29-AS-BBAI-DCVUFJ-20250113143249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800841
Report Date: 01/13/2025
Date Signed: 01/13/2025 02:33:20 PM

Document Has Been Signed on 01/13/2025 02:33 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AUTUMN MANOR, LLC		FACILITY NUMBER:	565800841
ADMINISTRATOR/ DIRECTOR:	GIOVANNI FULGENTES		FACILITY TYPE:	740
ADDRESS:	2770 HIGHGATE PL.		TELEPHONE:	(805) 582-2188
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	01/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Marie Mendez		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with the Administrator Giovanni Fulgentes and explained the reason for the visit. Licensee Mendez arrived shortly. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 10:30 a.m. Kitchen was observed to be inaccessible to residents in care. Knives and sharp objects are stored in a locked drawer to the right of the stove. Some cleaning supplies were observed kept underneath the sink inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. At the time of the visit, the common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in a hallway closet. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced on Aug 05, 2024. Activities were observed in the front room by entrance. The LPA observed four (4) resident bedrooms , which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit. LPA observed medication to be centrally stored and inaccessible in a cabinet next to bedroom #1. LPA observed the 2nd story of the facility to be for staff use only and inaccessible to residents in care.

Desaree Perera	TELEPHONE: (818) 596-4347
Brian Balisi	TELEPHONE: (818) 421-9171
	DATE: 01/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AUTUMN MANOR, LLC	FACILITY NUMBER: 565800841
	VISIT DATE: 01/13/2025

NARRATIVE

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All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care.

LPA observed garage to have a laundry area and to store, extra incontinent supplies, linen, PPE , as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. LPA observed a swimming pool with a six-foot fence inaccessible to residents in care.

Records review began at approx. 11:00am, three (3) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time . Last emergency disaster drill was conducted on 01/03/2025.

Medications review began at approx. 12:00 p.m. All medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the facility’s liability insurance. Interviews were conducted during the visit.

Exit interview conducted. A copy of the report was provided to License

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC809 (FAS) - (06/04)

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