565801486-7-28-2023-29-AS-ZCHN-CU62VW-20230727174437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801486
Report Date: 07/27/2023
Date Signed: 07/28/2023 09:42:57 AM

Document Has Been Signed on 07/28/2023 09:42 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AUTUMN MANOR, LLC #3		FACILITY NUMBER:	565801486
ADMINISTRATOR:	MARIA MENDEZ		FACILITY TYPE:	740
ADDRESS:	2747 ATHERWOOD AVENUE		TELEPHONE:	(805) 527-8281
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 5	DATE:	07/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Maria Mendez		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA observed two staff on duty. Reason for visit was stated. Staff contacted Administrator Maria Mendez.

The LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Administrator arrived shortly and continued the physical plant tour with LPA.

BEDROOMS: Resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four resident rooms, two which are shared and two private rooms. There is one staff room, which is kept locked. There was a linen closet in the hallway with extra towels and linens RESTROOMS: The two resident restrooms 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; towels and washcloths are not shared. COMMON AREAS: Living room and dining furniture was observed to be in good condition. There is a fireplace in the living room, which is covered and inaccessible. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were charged and were last serviced 7/12/2023. Exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space. KITCHEN: Knives are stored in a locked drawer, appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate for resident usage and is single latched. There were no bodies of water noted. The washer and dryer are held in the garage, including additional nonperishable and perishable food items. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. (continue to LIC809c)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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 #3	FACILITY NUMBER: 565801486
	VISIT DATE: 07/27/2023

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RECORDS: Personnel records reviews began at 11:45a.m. and were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The following was noted: According to Health and Safety Code 1569.625, required training topics not meet for three out of three staff files reviewed. Discussion held with Administrator Maria Mendez at great length regarding required training topics and better organization of training records to account for required training for staff during annual visit.

Resident records review began at 1:30pm; resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms, and hospice records. All resident records accounted for after a great length of research done by Licensee/Administrator (for hospice care plans and full rail orders).

MEDICATIONS: Medications review began at 3p.m.; 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 record. However a PRN authorization letter was not on file for resident #1 and the log for the cough syrup PRN medications was not completed.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code.

Exit interview conducted. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/28/2023 09:43 AM - 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 #3	FACILITY NUMBER: 565801486
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(c)

Other Provisions

(c) The training shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff training record review, the licensee did not comply with the section cited above in two out of two staff training records reviewed - this poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator agrees to audit all staff training records and ensure that all staff receive the required hours and training topics according to Health and Safety Code 1569.625c. Submit proof of audit, staff #1 and staff #2 's training according to regulation.

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
1 2 3 4	Based on resident record review, the licensee did not comply with the section cited above in one (1) out of 3 resident records reviewed - this poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	Licensee agreed to review all resident records; obtain and retain PRN authorization letter for R1. Licensee/Administrator agreed to do an audit of all resident PRN medication and ensure that residents PRN medication is dispensed according to regulations. Provide completed PRN medication audit and copy of the PRN authorization letter for each resident. Submit correction by 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.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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