Autumn Villas on Honors Drive

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Natasha Persaud conducted a Case Management - Other visit. LPA was greeted and allowed entry into the facility by Staff, Elvia Jimenez. An annual inspection was conducted on 02/24/26. During the inspection, staff were asked if the video surveillance had audio. Staff members confirmed some of the cameras had audio. Audio is not allowed with video surveillance. Today, the assistant administrator disconnected all three (3) cameras and stated they will be replaced and audio will not be used. Assistant Administrator explained they will discuss the camera option with the licensee and notify Community Care Licensing. A deficiency is being issued for using audio with video surveillance. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Assistant Administrator, Meredith Pritchard-Malo whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(1) · Plan of correction due date: Mar 4, 2026

Personal Rights. To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure 5 out of 5 [R1-R5] clients were provided dignity and privacy by the cameras having audio, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: Assistant Administrator disconnected and removed all mounted cameras and agreed not to use cameras with audio. POC corrected.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Alexandra Holm. House Manager, Meredith Pritchard-Malo arrived during the visit. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 119 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. Review of resident records indicated R#6 did not have TB test results on file. The infection control plan was not readily available at the facility. Staff confirmed the plan was completed. However, they have not been trained on the infection control plan. The facility did not have training on file for their Emergency Disaster Plan. No deficiencies were observed or cited during today's annual inspection. However, Advisory Notes were issued. An exit interview was conducted with House Manager, Meredith Pritchard-Malo to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. LPA was away from the facility for approximately one hour between 1:30pm and 2:30pm.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Case Management - Other

On 7/1/25, Licensing Program Analyst (LPA) Arian Golbakhsh conducted and unannounced Case Management visit to conduct a brief Health and Safety visit as well as to follow up on a Hospice Waiver request from the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Danielle Thurman. Assistant Administrator Meredith Pritchard-Malo arrived later during the visit. LPA briefly toured the facility, conducted file review and obtained copies of records, and spoke with staff and residents. LPA did not observe any immediate health and/or safety violations and after speaking with residents did not receive any complaints about their wellbeing. LPA observed residents participating in activities and staff preparing meals. LPA provided consultation with Assistant Administrator Pritchard-Malo regarding hospice waivers and exceptions. No deficiencies were cited during the visit. An exit interview was conducted with Assistant Administrator Pritchard-Malo to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, Required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Danielle Thurman. The facility's license shows a maximum capacity of six (6) non-ambulatory residents age sixty (60) or above. The facility is approved for one (1) bedridden resident, who must reside in room number three (3). During today’s inspection there were six (6) residents in care. LPA and caregiver Dillan Ena toured the interior and exterior of the facility and inspected each room. Assistant Administrator Meredith Pritchard-Malo arrived later during the visit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink 1 read at 105F, bathroom 2 read at 114F, and the kitchen tap read at 111F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per caregiver Dillan, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed two (2) staff and zero (0) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, aside from staff training of fire drills. Confidential records were stored in locked areas. A deficiency was cited during the inspection for the lack of fire drills conducted as required. An exit interview was conducted with Assistant Administrator Pritchard-Malo to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 10, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management-Annual Contnuation visit. The LPA introduced himself and disclosed the purpose of the visit with Caregiver Danielle Thurman. Administrator's Assistant Meredith Pritchardmalo arrived during the visit and assisted the LPA. The facility was licensed for a capacity of six (6) non-ambulatory residents, with one being able to be bedridden in room # 3. During the Annual visits, the LPA, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, and stored in locked areas. No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide , and facility telephone were operational. A fire extinguisher and first aid kit were readily accessible. Required licensing postings were observed in visible areas of the facility. The LPA interviewed staff and reviewed multiple staff and client records/files. Deficiencies were cited in an LIC 809D, and a plan of correction was jointly formulated with Pritchardmalo. An exit interview was conducted with Pritchardmalo, to whom a copy of this report, LIC 809D, LIC 811, and Applicant/ Licensee Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Jan 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 29, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: Based on review of records, the Licensee did not ensure resident (R5) had annual medical assessment, which posed a health, safety, and personal rights risk to 1 of 6 residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Administrator's assistant agreed to submit a completed Physician's Report for R5 to the LPA, by 2/9/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Jan 29, 2024

87411 Personnel Requirements - General (c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This was not met as evidenced by: Based on review of records, the Licensee did not ensure staff (S2,S3, and S4) had 1st aid training, which posed a potential health, safety, and personal rights risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Administrator's Assistant agreed to submit proof of1st aid training for S2, S3, and S4, by 2/9/24. On a continuation annual visit, the LPA confirmed S2 and S3 had recieved 1st Aid training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Jan 29, 2024

87411 Personnel Requirements-General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement was not met as evidenced by: Based review of records, the Licensee did not ensure staff (S1,S2,S3, and S4) had a health screening, which posed a health, safety, and personal rights risk to 6 of 6 persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Administrator's Assistant agreed to obtain health screenings for staff (S1,S2,S3, and S4), and submit proof to the Department, by 2/9/24.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Sabel Martinez conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Danielle Thurman. Administrator assistant Meredith Pritchardmalo arrived during the visit and assisted the LPA. During today’s visit, The LPA toured the facility, and reviewed staff and resident records. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with the Pritchardmalo, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were providedthe state’s words, verbatim · CDSS document, Jan 24, 2024