Autumn Hill

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Administrator and granted entry. LPA began inspection with introduction, visit purpose and provided the Administrator with LPA identification and business card. Resident record review began- Three (3) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Two (2) records were reviewed. LPA reviewed employee record for first aid certification-1 missing, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current; expires 8/13/2026. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 110.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the designated area. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. (Continued on next page) (Continued on from Page 1) Food Service- Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. Additional emergency water was not observed. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 8/22/2025. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 01/29/2026. Based on the information received during this visit today, there are two (2) deficiencies that is being cited per Title 22, Division 6 of The California Code of Regulations. This report, 809D and Appeal Rights was reviewed with Cecilia Barna and a copy provided at the time of the exit interview. Licensee will be sending copies of LIC308, liability insurance, LIC500 by 5/5/2026,the state’s words, verbatim · CDSS document, Apr 24, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Administrator and granted entry. LPA began inspection with introduction, visit purpose and provided the Administrator with LPA identification and business card. Resident record review began- Three (3) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 110.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the designated area. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. (Continued on next page) (Continued on from Page 1) Food Service- Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 8/27/2024. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 04/08/2025. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with Cecilia Barna and a copy provided at the time of the exit interview. Licensee will be sending an LIC200 with updated facility sketch to decrease capacity.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Licensee Cecilia Barba, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and three (3) residents present. The facility is licensed for six (6) residents, whom may be non-ambulatory, with one (1) who may be bedridden. The facility has a hospice waiver for four (4) residents. A dementia program is also on file. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present.The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were stored and inaccessible to clients. The sharp and dangerous objects were observed to be locked and inaccessible to residents. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed two (2) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Three (3) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate. Resident medication was centrally stored and locked in a cabinet located in the kitchen. LPA reviewed medications prescribed to the residents and found all medication listed on MARS and all required labeling was found to be in place. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Fire extinguishers were fully charged and inspected. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Licensee Barna.the state’s words, verbatim · CDSS document, Apr 29, 2024