Autumn Grove Care Home

Type of visit: Required - 1 Year

On October 29, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA Tirre was greeted by staff and granted entry after stating the purpose of the visit. Staff contacted Administrator Patricia O’Connel to notify of Licensing visit. Caregivers Mack Delos Reyes and Lilian Manlulo were able to assist with inspection visit. The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for four (4) residents. Currently facility has capacity of six (6) residents of which four (4) Hospice residents present during today’s visit. This is a single story with attached car garage facility. The facility has five bedrooms (two shared resident rooms and two private rooms) one staff room, and three bathrooms (two for residents and one for staff). LPA conducted a tour of the physical plant accompanied by staff, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 110.6 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for toxins, cleaning supplies and sharps objects were stored and not accessible to residents. CONTINUED ON 809C The kitchen was inspected, and sufficient two day perishable and seven day non-perishable food was maintained adequately. Facility has one fire extinguisher which was mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance. Facility has supply of emergency food and water. During the visit, LPA observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. The last fire drill was conducted on October 3, 2025. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 12/25/2024 – 12/25/2025. A review of six residents (R1-R6) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Patricia O’connell # - 7006170740 expiration 9/25/26. No deficiencies during this inspection visit. An exit interview was conducted with Caregiver Mack Delos Reyes, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Nancy Guillen and Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPAs were greeted and granted entry by Staff #1 at 1:45 PM. During today’s visit, LPAs met with Menandro Tanuyan, Administrator Designee. The facility is a single story, five bedroom, three bathroom residential home with an approved fire clearance of six non-ambulatory residents of which four may be on hospice. The facility currently has a census of six residents in care, of which four are on hospice. During today’s visit, LPA Guillen toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperatures in two of two resident bathrooms. A third bathroom is primarily for staff. The hot water temperatures measured between 119.4 and 120 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on October 29th,2024. The facility’s last fire drill was conducted in 2023. LPAs observed the PUB 475 poster was not the 20" X 26" required size and advised staff to post the theft and loss and visiting hours in a prominent place near the entryway. LPAs inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA Guillen observed spices were past expiration dates and immediately removed them. LPA Guillen advised staff to continue to look through pantry for any additional expired items and to throw them out. LPA Ruppert observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. (Continued on LIC 809-C) (Continued from LIC 809) LPAs reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPAs interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPAs confirmed that administrator has an active administrator certificate which will expire on August 29th, 2026. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Menandro Tanuyan, Administrator Designee and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 9102-TV, LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Nov 22, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.