198601220-3-29-2024-11-AS-FSHY-D3CRDU-20240314125631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601220
Report Date: 03/14/2024
Date Signed: 03/29/2024 03:50:11 PM

Document Has Been Signed on 03/29/2024 03:50 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	AUTUMN I ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198601220
ADMINISTRATOR:	AISHA ANDREWS		FACILITY TYPE:	735
ADDRESS:	2423 W. 73RD STREET		TELEPHONE:	(323) 754-3906
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90043
CAPACITY:	6	CENSUS: 4	DATE:	03/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Debra Davenport, Supervisor		TIME COMPLETED:	01:00 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	On 3/14/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA was met by staff Freddie Garcia and later Debra Davenport, House Supervisor and explained the purpose of today’s visit and was granted entry. The facility has a census of 4. One resident is in day program. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (2) bathrooms, kitchen, dining area, living room, garage, shaded porch, and back yard. Facility maintains all required posting throughout the facility and in a binder for facility documents. LPA Shirley and Debra Davenport toured the physical plant. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 113.3 F. All fire extinguishers were operable. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguishers were charged, smoke detectors and carbon Monoxide were operable. LPA observed sensors on all doors, checked first aid kit; and found that it was compliant with a manual. Con'd 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AUTUMN I ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198601220
	VISIT DATE: 03/14/2024

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
26
27
28
29
30
31
32

A review of Medication Records Administration (MAR) was observed to be maintained in order with documented dates. During the visit, LPA observed the facility's infection control practices.

There are no bodies of water or firearms on the premises.

LPA also observed that the facility has a 60-day supply of Personal Protective Equipment (PPE). And all mandated posters were posted.

There were no deficiencies observed during today’s visit. Exit interview held and a copy of the report was provided to the House Supervisor, Debra Davenport.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2