Autumn Elder Care

Allegation investigated: Staff did not provide proper notice of increase in rate.

At 09:15am, Licensing Program Analyst (LPA), Angela Panushkina and Licensing Program Manager (LPM), Nichelle Gillyard conducted an unannounced visit in response to the above-mentioned allegation. LPA/LPM met with the Staff #1 (S1), who granted access to the facility. Administrator was contacted and the reason for the visit was explained. At 09:20am, LPA/LPM requested resident and staff roster. At 9:25am requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, Resident Daily Log, relevant to the investigation. At approximately 9:30am, LPA/LPM conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 9:50am – 11:00am, LPA/LPM interviewed one (1) staff, three (3) residents and one (1) witness. Continue on LIC9099-C Substantiated Allegation: Staff did not provide proper notice of increase in rate. It was alleged that the facility provided a rate increase notice for R1 due to the high level of care required by the staff. To investigate this allegation LPA/LPM conducted an interview with S1 and were informed that R1 was admitted to this facility on 04/18/25. R1 required full assistance with the Activities of Daily Living (ADLs). LPA/LPM were also informed that R1 would call at 2:00am and request to pull the pillow up or ask for an ice among other basic tasks. S1 provided copies of R1’s daily notes. LPA/LPM conducted review or R1’s daily notes and observed that R1’s level of care remained the same from April 20th, 2025 to May 30th, 2025. Additionally, LPA/LPA conducted review of R1’s Preplacement Appraisal and Appraisal Needs and Service plan (dated on 04/18/25) and Physician’s Report (dated on 04/18/25) and observed that both documents indicated that R1 had various health, mental and physical condition. LPA/LPM asked S1 about major change in R1’s health condition between April 18th, 2025, and May 31st, 2025, and there was no change in health or medical condition.Review of R1’s level of care appraisal letter submitted by the licensee (on 05/12/2025) did not specify and changes in R1’s health condition but expressed assistance with basic need and requests which include but not limited to asking for ice,straighten bed and pillow during late hours. This is not sufficient reason to increase the rent. No updated reappraisal was observed to support the letter. Therefore, the rate increase was invalid and improperly requested. Lastly, according to Health and Safety Code 1569.55, any increase in rates, require a (60 days) written notice, and the notice must include the reason for the increase, as well as a detailed description of the additional cost. Based on the interviews and record reviews, this allegation is Substantiated. Deficiency cited on LIC9099-D Exit interview conducted, appeal rights explained and copy of this report signed and delivered. Allegation: Staff inappropriately speaks to resident. It was alleged that Staff #1 (S1) inappropriately spoke to R1. To investigate this allegation LPA/LPM conducted an interview with S1, who denied the above allegation and informed LPA/LPM that he/she always assisted R1 and other residents with dignity and respect. In addition, three (3) residents interviewed expressed no concerns regarding this allegation. Interview also revealed that they have not witnessed nor heard staff inappropriately speak to R1 and or other residents. Lastly, interview with the witness revealed that the facility staff is very professional and he/she never witnessed S1 inappropriately speak to residents. Based on interviews there is insufficient pertinent information to support the allegation. Therefore, the allegation is Unsubstantiated, at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 12, 2025 · control 31-AS-20250605153846

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Jun 19, 2025

Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase... (a) If a licensee of a residential care facility... setting forth the amount of the increase and the reason... including a description of the additional costs This requirement is not met as evidenced by: Based on interviews and record reviews, licensee did not comply with the section cited above, by issuing improper rate increas to R1, which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 12, 2025

Plan of correction: POC is cleared during today's visit. LPA/LPM were informed that R1 moved out from the facility on 05/31/25

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Panushkina and Licensing Program Manager (LPM) Nichelle Gillyard, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20250605153846. LPA met with the Staff #1 (S1) and explained the reason for the visit. During the physical plant tour, conducted at 9:30am, LPA/LPM observed the following: Kitchen cabinets were missing two (2) knobs and the cabinets were dirty and greasy. Refrigerator was dirty inside an out with food debrief The oven was dirty and greasy Room #3 walls had pealing paint and dirty marks. Room #3 window ledge was in disrepair Floor planks were in disrepair in various areas of the facility and can be a potential tripping hazard. The sliding door in the living room did not easily open. All bathroom cabinets have chipping paint and were soiled and dirty. The bathroom cabinet (in the master bedroom) was missing a knob. During the visit LPA/LPM discovered that there is an intent to sell the facility to one of the Staff. Health and Safety Code 1569.191(b)(2) was explained. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC809-D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Jun 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 19, 2025

Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement is not met as evidenced by: Based on LPA/LPM observation, the licensee did not comply with the section cited above by not having a clean facility and in good repair, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 12, 2025

Plan of correction: Administrator will clean, replace, repair anything indicated in this report. Licensee will clean, replace, repair anything that was missed during the physical plant tour. Plan will be emailed to LPA by POC date

Type of visit: Required - 1 Year

At 9:30 AM, Licensing Program Analysts (LPAs) Angela Panushkina and Huma Rahimi conducted an unannounced annual visit. LPAs met with the Eleonor Blass, Staff #1 (S1), who granted access to the facility and then contacted the Administrator. Administrator arrived shortly after and LPAs explained the reason for the visit. The facility is licensed for six (6) non-ambulatory, of which one (1) may be bedridden. All bedrooms are cleared for bedridden residents. In addition, the facility has a hospice waiver approved for six (6) residents. Kitchen: At approximately, 9:50am LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. LPAs observed two (2) prescribed (narcotic) medications stored in the kitchen refrigerator and accessible to residents. LPAs did not observe a medication box nor a lock available. Facility currently has Dementia residents in care. Medications: At approximately, 10:00am LPAs observed medications are centrally stored and locked in a 6-drawer cabinet, by the kitchen. However, one (1) of the drawers (bottom, right) was broken and LPAs observed medications were accessible to residents in care. Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are clean and have appropriate bedding and linens. LPAs observe a two (2) top drawers in bedroom #1 were broken. Auditory alarms were tested and observed to be operational. One (1) bedroom is designated for live-in staff and during the tour, LPAs observed a window screen was loose. Bathrooms: At 10:25am LPAs observed two and half (2½ ) bathrooms are clean. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 126.1 and 127.2°F. LPAs observed appropriate grab bar and had non-skid mat. LPAs observed a bathroom window screen in Continue on LIC809-C room #5 was loose. All trash cans in bathrooms had fitted lids to protect from cross contamination. Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:30am they were tested and observed to be operational. Carbon monoxide was located by the entrance and also tested and observed to be operational. Common Areas: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher by the kitchen and was last serviced on 08/09/2024. Outside areas: At approximately, 11:50am LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. LPAs also observed a garden tool accessible to residents in care and old kitchen sink with old counter boards placed against the wall. LPAs requested all unnecessary items to be stored in a storage or thrown away. LPAs also discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water. The garage: Laundry area is located in an attached garage and LPAs observed all detergents kept locked and inaccessible to residents. Extra food storage was also observed. LPAs also observed hospice emergency kit in refrigerator. However, the box had no lock and it was accessible to residents in care. Between 11:55am to 1:30pm, LPAs reviewed records of five (5) residents and three (3) staff. Residents and staff records appeared to be complete and updated. Administrative: LPAs collected Certificate of Liability Insurance and LIC500. Deficiencies cited on LIC809-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 31, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Angela Panushkina and Leslie Ngo-Castaneda conducted unannounced visit to this facility. LPA met with the Administrator and explained the reason for the visit. During 06/21/24 visit conducted by LPA Panushkina, the facility had been issued three (3) deficiencies and the Administrator had to submit all Plan of Corrections (POC) by 06/28/24. LPA collected all proof and cleared POC's during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jul 2, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240513103627. LPA met with the Designee and explained the reason for the visit. On 05/13/24, the Regional Office (RO) received a complaint and on 05/16/24, LPA conducted an initial complaint visit. After the final report was delivered, an Informal Meeting was conducted with the Administrator on 05/29/24 to discuss the deficiencies, and it was determined that an additional deficiency will be issued. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC809-D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Jun 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.74(b)(6) · Plan of correction due date: Jun 28, 2024

(b) Any policy established pursuant to subdivision (a) shall meet all of the following conditions: (6) Facility staff are prohibited, on behalf of any resident... ...from being the legally recognized surrogate decision maker. This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the section cited above by failing to communicate with R1 regarding changes in level of care and made a decision on R1's behaf by not accepting R1 back or potentially transferring R1 to her other facility/location, which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Administrator agreed to complete a written statement of understanding on how the facility will follow section 1569.74(b)(6). Statement must be submitted to LPA by POC date

Type of visit: Office

An informal meeting was held today at the Woodland Hills Regional Office to discuss recent deficiencies and provide guidance to ensure future compliance. Prior to the meeting, Licensee was given the chance to review the facility file. Present at today's meeting were the following: Myline Olivas - Administrator Nichelle Gillyard - Licensing Program Manager (LPM) Angela Panushkina - Licensing Program Analyst (LPA) The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Meeting can lead to an Administrative Action Process. BRIEF HISTORY: The facility Autum Elder Care has been in operation since licensure on 11/20/2020 From November 2020 to present, the Department received four (4) complaints, two of which were found Substantiated. Continue on LIC809-C LPM and LPA discussed reporting requirements. The Administrator has agreed to submit an incident report in regards to resident which was recently hospitalized. LPM clarified how the Plan of Correction days are counted. LPM will address Appeal in regards to Unusual Incident Reports. On 05/16/2024 an unannounced complaint visit was conducted by LPA Panushkina and the facility regarding the EVICTION PROCEDURES. LPA will continue and re-open an investigation to conduct interviews and if necessary, will issue an Amended report Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 29, 2024

Allegation investigated: Illegal eviction.

This is an Amendment to the original report issued 05/16/2024. Additional information was added to clarify the investigation. At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with the Administrator and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:05am, LPA requested resident and staff roster. At 10:10am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Eviction Letter, etc., relevant to the investigation. At approximately 10:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Continue on LIC9099-C Substantiated Between 10:20am – 12:30pm, LPA interviewed the Administrator, two (2) staff and two (2) out of six (6) residents, who were able to communicate. It was alleged that the facility did not accept R1 after hospital discharge. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that upon R1's admission on 04/29/24, the Administrator attempted to arrange home health for R1's wound care. Five (5) Home Health agencies were contacted so that a proper medical care could be provided to R1. However, all five agencies refused/were unable to assign a Home Health to R1 due to insurance coverage limitations. On 05/09/24, was hospitalized and level of care for R1 changed; and therefore, the facility could not accept R1 back to the facility. Upon LPA’s request, the Administrator could not provide sufficient document regarding R1’s changes in the level of care. Additionally, the investigation revealed the Administrator did not submit the Eviction letter to the Community Care Department nor served a copy of 30-day Eviction notice to R1/family/representative. On 06/13/24, a telephonic interview with R1 revealed that R1 had anticipated going back, however, the hospital doctor stated that R1 requires a higher level of care. No re-appraisal and no conversation with R1 was done by the facility's Administrator to inform that the facility can no longer meet R1's needs based on what the hospital/doctor said. Based on interviews and record reviews this allegation is Substantiated at this time. Deficiency cited on LIC9099-D Exit interview conducted, appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20240513103627

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: May 23, 2024

Eviction Procedures-The licensee may, upon thirty (30) days written notice to the resident, evict the resident for development of a need not previously identified. This requirement is not met as evidenced by: Based interviews and record reviews, licensee did not comply with the section cited above, by failing to properly evict R1. On 05/09/24, R1 was hospitalized and not accepted back to the facility, which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Licensee will ensure that Title 22 Regulations are followed for eviction procedures. Administrator will send statement that any resident that is evicted will be afforded the ability to go through the proper eviction process.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jun 28, 2024

Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical... This requirement is not met as evidenced by Based on interview and record reviews, licensee did not comply with the section cited above. Adminsitrator confirmed that upon R1's discharge from the hospital, R1's reappraisal was not updated, which poses/posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Administrator agreed to submit a statement of understanding on how all residents will have a proper reappraisal when changes occur and discharged from the hospital to ensure their needs are met. Proof of statement shall be submitted to LPA by POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240513103627. LPA met with the Administrator and explained the reason for the visit. During the visit, LPAs was informed that per R1's doctors' request, R1 was taken to Northridge Hospital on 05/09/24, where it was determined that R1 had to be hospitalized. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPA informed the Administrator to submit an incident report that occurred on: 05/09/24 (one incident) Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, May 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: May 23, 2024

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 05/09/24, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date.

Type of visit: Required - 1 Year

At 12:15pm Licensing Program Analysts (LPAs), Leslie Ngo-Castaneda, Angela Panushkina, and Huma Rahimi conducted an unannounced annual inspection at the facility mentioned above. LPAs were greeted by the staff, Sheila Reano who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit. Physical tour was conducted with the Administrator and LPAs observed the following: Kitchen: At approximately, 12:20pm LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a drawer and inaccessible to clients in care. Fire extinguisher in the kitchen was purchased on 08/21/2023. Medications: At approximately, 12:35pm LPAs observed medications are centrally stored and locked in the dining room cabinet. Bedrooms: There are four (4) bedrooms designated for clients use with sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Staff bedroom was observed to be locked and inaccessible to clients in care. Bathrooms: At 12:45pm LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPAs observed appropriate grab bar and client's bathroom had non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Hot water temperature measured at 111°F. Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area Continue on LIC9099-C appeared clean and were properly furnished. The living room has a television, comfortable furniture and the fireplace is adequately screened. No obstructions and or tripping hazards throughout the facility. Laundry is located in the attached garage that can be accessed through the living room. LPAs observed all detergents locked and inaccessible to residents in care. Extra PPE supplies and food storage was also observed. Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 1:20pm they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational. Outside areas: At approximately, 1:25pm LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. There is no bodies of water. LPAs discussed the importance of maintaining the care and supervision to meet the needs of clients. Between 2:20 to 2:50pm, LPAs reviewed records of four (4) clients and two (2) staff. Client and staff records appeared to be complete and updated. Administrative: LPAs collected Certificate of Liability Insurance, and LIC.500. No citations issued during this visit. Exit interview conducted. Copy of report emailed to the Administrator.the state’s words, verbatim · CDSS document, Oct 5, 2023