Autumn Grove Senior Living

Type of visit: Required - 1 Year

On July 3, 2026, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility unannounced to conduct the annual inspection visit. LPA initially met with staff on duty and stated the purpose of the visit. The Administrator, Andre Albason (AD), was notified and arrived shortly after. Present during this visit were 5 residents in care with 2 staff on duty. Overview: Facility is a one-story house located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, up to 4 may be non-ambulatory. Facility does not have clearance for bedridden, delayed egress, and/or locked exterior and/or interior. Physical Inspection: Areas inspected include, but not limited to, the kitchen, dining, resident units/bedrooms, resident bathrooms, common areas and outdoor areas. LPA inspected 3 of 4 bedrooms. One of the bedrooms (Bedroom #4 on the facility sketch) has an exit. In bedroom #4, LPA found resident medications inside the closet. Per review of residents’ medical assessment (LIC602A), at least one resident was assessed to be at risked if they have access to medications and similar items. Two bathrooms were inspected. In one of the bathrooms, LPA found medication in one of the cabinet. Hot water temperature ranged from was measured at 114 degrees Fahrenheit. Hallway temperature was between was maintained at 76 degrees Fahrenheit. Fire extinguisher was observed in the kitchen and hallways and was last inspected on January 22, 2025. There is a fire door leading to bedrooms #2, #3, and #4. During this visit, the fire door was propped open. Per staff interview, they keep this fire door open at all times. Staff closed the fire door during this visit. Smoke and carbon monoxide detectors were observed throughout. {1 of 2} In the laundry room, LPA observed cleaning supplies, rubbing alcohol, and air refreshers to be unlocked and accessible to residents. Inside the garage, LPA observed cleaning chemicals that were stored in the same storage as drinks. There is an additional freezer in the garage. In the kitchen area, LPA observed at least seven-day non-perishable and two-day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. Kitchen refrigerator and freezer were maintained at regulatory temperature. The outdoor areas: LPA observed shade area and outdoor furniture for residents use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. Fence and gate were in good repair. Advisory provided to licensee to ensure they know the location of each shut off valves and how to operate each one in case of emergency. Advisory also was provided for staff to remove the extra locking mechanism of the exit gate. Record Reviews: LPA reviewed 4 resident files and 2 staff files Review of resident files, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. LPA reviewed 1 of 5 resident medications. Advisory given for staff to obtain PRN Authorization Letter for all residents. At least one resident did not have a completed Care Plan (LIC625). Review of staff files included, but not limited, background clearance, First Aid/CPR certificate, Health Screen, Initial Training. Per review of Guardian, 2 staff on duty are associated with this facility. Review of fire drill/disaster drill records: facility conducts quarterly drills and last drill was conducted on 4/22/2026. Documents Requested: LPA requested a copy of current LIC500, LIC308 and Liability Insurance Certificate to be emailed at arvin.villanueva@dss.ca.gov Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited at this time. Advisories were provided. Immediate Civil Penalties were assessed in the amount of $500 during this visit for violation of fire safety. Exit interview was conducted. A copy of the report was provided upon exit. {2 of 2}the state’s words, verbatim · CDSS document, Jul 3, 2026

The state marks this report as 20 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Post Licensing

On July 3, 2026, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility unannounced to conduct the annual inspection visit. LPA initially met with staff on duty and stated the purpose of the visit. The Administrator, Andre Albason (AD), was notified and arrived shortly after. Present during this visit were 5 residents in care with 2 staff on duty. Overview: Facility is a one-story house located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, up to 4 may be non-ambulatory. Facility does not have clearance for bedridden, delayed egress, and/or locked exterior and/or interior. Physical Inspection: Areas inspected include, but not limited to, the kitchen, dining, resident units/bedrooms, resident bathrooms, common areas and outdoor areas. Record Reviews: LPA reviewed 4 resident files and 2 staff files Review of resident files, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Review of staff files included, but not limited, background clearance, First Aid/CPR certificate, Health Screen, Initial Training. Citations and advisories were provided in the annual report. Exit interview was conducted. A copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Jul 3, 2026

Allegation investigated: Staff illegally evicted a resident in care.

On 03/11/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an complaint visit. LPA Pascua was greeted by Staff Member (SM), Eljane Navalon and explained the purpose of the visit. LPA Pascua asked SM Navalon to contact the Facility Designated Administrator (FDA), Andre Albason and notify them that CCL was present at this time. LPA Pascua was able to speak with FDA Albason via telephone and identify the purpose of the visit. FDA Albason stated that they would arrive at the facility within 20 minutes. At 1:15pm, FDA Albason arrived at the facility. Current census was 5. A brief interview with FDA Albason was conducted. During the course of this visit. LPA Pascua conducted interviews, reviewed facility records and toured the facility. It was alleged that staff illegally evicted resident in care. It was learned that the facility resident is still residing at the facility and the facility has not issued an eviction notice at this time. Based on documents reviewed and interviews with staff the above allegation is UNFOUNDED. The department has determined that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Unfounded A review of the facility records were conducted, it was observed that this resident did not have a tendency of wandering from their pre-appraisal however communication was conducted to inform the residents responsible party of the incident. Since the incident, facility administrator has implemented staffing and increased supervision to ensure the health and safety of the resident in care. Based on the information gathered, there is not sufficient evidence to prove that the facility staff did not prevent a resident from eloping from the facility. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 27-AS-20260302165112

Allegation investigated: Staff does not have required training Staff did not seek timely medical care for resident Staff leave resident in soiled diapers/linins for an extended period of time Staff did not follow physician's orders

On 2/06/26, Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to deliver fingings for the above allegation. LPA identified herself upon arrival, stated the purpose of the visit. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are nothe state’s words, verbatim · CDSS document, Feb 6, 2026 · control 27-AS-20251215150153

Allegation investigated: Staff is not fingerprint cleared to provide care and supervision to residents.

On 12/18/25, Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit. LPA met with Alicia Moreno and a brief interview followed. LPA requested and reviewed staff files all files were complete and all staff who were currently at the facility were fingerprint cleared, also all staff that had files at the facility were cleared. LPA also interviewed R1-R2 and S1-S2. Based on documents reviewed and interviews with staff the above allegation is UNFOUNDED. The department has determined that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview and copy of report given. Unfoundedthe state’s words, verbatim · CDSS document, Dec 18, 2025 · control 27-AS-20251215151057

Type of visit: Prelicensing

On 7/14/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived announced at this facility to conduct the prelicensing inspection visit. LPA met with Licensee/Administrator Andre Albason, and stated the purpose of the visit. Overview: Facility is a one-story home located in a residential neighborhood. Facility will be licensed to serve up to 6 elderly residents, 2 of which are ambulatory and 4 are non-ambulatory . Facility has 4 resident bedrooms and two resident bathrooms. Bedrooms #2 and #3 may be occupied by non-ambulatory residents provided bedroom #4 has no privacy lock as the exit door in bedroom #4 shall be accessible in case of an emergency. Outdoor Area: Front yard was observed to be maintained and clear of debris and obstruction. There is an area in the backyard equipped with outdoor furniture with umbrella located next to a tree for shade. Outdoor passageways, walkways, driveways, and steps are free from obstructions. Fence and gate are in good repair. No swimming pools/bodies of water at this time. Residents' Bedrooms: LPA inspected 4 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. Each bedroom has smoke and carbon monoxide detector. Resident bedroom #1 is located near the front door. A fire door was observed leading to the other resident bedrooms. Bedrooms #1 and #3 will be single occupancy. Bedrooms #2 and #4 will be shared. Bedroom #4 has its own bathroom and exits the backyard. This exit will be accessible as an emergency exit. {Con't to 809-C} {Con't from 809} Bathroom: Facility has 2 resident bathrooms. One bathroom in the hallway and the other bathroom is inside bedroom #4. Both bathrooms have working toilets, wash basins and full baths with showers. Both bathrooms are equipped with non-skid flooring and close-lid garbage bins. LPA provided an advisory to install a grab bar in the toilet area for the bathroom in bedroom #4. It was installed during this visit. Linens & Hygiene Supplies: Adequate supply of linen and hygiene supplies stored in linen closet, located in the resident hallway. Emergency Phone Numbers, Exit Plan & Menu: Emergency Disaster Plan will be posted & available for review. Two fully charged fire extinguisher were found in the kitchen/dining room and in the resident hallway. Fire extinguishers were last serviced on 1/22/25. Dangerous Items: Toxins and chemicals were locked/stored under kitchen sink and in the laundry area and are inaccessible to residents. Water temperature: Hot water temperature was taken in one bathroom and measured at 105*F. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in locked drawers. Smoke Detectors and carbon monoxide: Facility has smoke detectors/carbon monoxide monitor combination. LPA observed one in each resident bedrooms, hallway, living room and in the kitchen/dining room area. They were tested and found in good repair at this time. Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator/freezer in the kitchen. Advisory was provided to obtain thermometer for both the refrigerator and freezer to ensure regulatory temperature is maintained for proper food storage. Washer and dryer are located in the laundry room, leading to the garage area. Medications, First-Aid Kit & Records: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet in the kitchen/dining area, available for staff use but inaccessible to residents. There is a medication cabinet that was observed to be locked. Residents & Staff Files: Applicant will not be handling cash resources of residents at this time but will submit necessary documents for any changes. {Con't 809-C} {Con't from 809-C} Activity Supplies/Materials: During this visit, LPA observed Bingo, Connect Four, Jenga, and books. Advisory was provided for licensee to provide future residents with a variety of activities and choices. Component III: LPA reviewed Component III with Andre Albason. The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 14, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Jun 12, 2025