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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800976
Report Date: 05/26/2023
Date Signed: 05/26/2023 04:46:29 PM


Document Has Been Signed on 05/26/2023 04:46 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 #2FACILITY NUMBER:
565800976
ADMINISTRATOR:GIOVANNI FULGENTESFACILITY TYPE:
740
ADDRESS:2365 KENTFIELD ST.TELEPHONE:
(805) 526-8629
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 2DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria MendezTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived to this facility today to conduct a required annual visit. Upon arrival LPA met with staff who contacted Administrator Maria Mendez. Reason for visit was explained. Administrator arrived to the facility at approximately 10:30am.

The LPA and Ms. Mendez 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. BEDROOMS: The LPA observed two double-occupancy and two single-occupancy resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms observed clean and sanitary and in operating condition. Hot water temperature is maintained within required range. KITCHEN: Knives were stored in a locked drawer and cleaning supplies were stored a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguishers appeared fully charged and was last inspected in 07/2022. The backyard patio is equipped with furniture for residents' use.

RECORDS: Resident records review began at 11:30am.: resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order. Staff records review began at 12pm and were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, and first aid/CPR training. Additional required training records reviewed at approximately 12:30pm. The following was noted: staff #1 did not have record of four hours of training, which shall be specific to postural supports, restricted health conditions, and hospice care. Trainer information not recorded; training time not recorded. Disaster Preparedness - Emergency and Disaster Plan reviewed at approximately 1:30pm. Plan was completed however not reviewed since 2020. (cont. LIC809c)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12


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 #2
FACILITY NUMBER: 565800976
VISIT DATE: 05/26/2023
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MEDICATIONS: Medications, records, and procedures reviewed at approximately 2pm.; medications are centrally stored and locked in a cabinet in the living room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.


Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 05/26/2023 04:46 PM - It Cannot Be Edited

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 #2
FACILITY NUMBER: 565800976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee did not have a complete file for the administrator for review during todays visit. This poses/posed a potential personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Licensee agrees to maintain an administrator file for current administrator at the facility. Submit packet for administrator to update administrator for this facility.
Request Denied
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 staff out of 2 staff files reviewed; staff 1 lacked required training referenced above. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Licensee agrees to provide additional training to staff 1 for the topics listed in the health and safety code. Provide a self certification that training was completed and submit copy of training record for staff 1.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 12


Document Has Been Signed on 05/26/2023 04:46 PM - It Cannot Be Edited

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 #2
FACILITY NUMBER: 565800976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 resident medication and medication records reviewed. This poses/posed a potential health, safety or personal rights risk to persons in care.
Resident 1 (R1) and resident 2 (R2) did not have the PRN authorization letter on file.
POC Due Date: 06/09/2023
Plan of Correction
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Licensee agreed to obtain and submit PRN authorization letter to R1's and R2s doctor. LIcensee also agreed to develope and maintain a corresponding log for residents who are unable to determine/clearly state symptoms for any PRN mendication. Provide completed copy to LPA for proof of correction.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 12