Autumn Manor, LLC #2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Licensee Maria Mendez arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. At approx 10:05a.m. The LPA inspected the kitchen/food service area. Kitchen appliances appeared clean and to be in operable condition at the time of the visit. At approx 10:15 a.m. LPA observed staff mopping floors. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps were observed locked and inaccessible to residents in care. LPA observed four (4) resident bedrooms , which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit. LPA observed personal hygiene supplies and toiletries to be centrally stored and inaccessible in a hallway cabinet. There was one (1) staff room, which was observed to be empty during the time of the visit. At approx 10:38 a.m. LPA observed staff playing piano with the staff. LPA observed the common area furniture's to be in good condition. A sufficient supply of clean linen and towels were observed stored in a hallway closet. The facility maintained a comfortable temperature of 72 degrees Fahrenheit Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced on 08/11/2025. There is an office area located next to the kitchen. LPA observed facility and resident files to stored inaccessible to residents in care. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to have a laundry area and to store, extra incontinent supplies, linen, PPE , as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. LPA did not observe any bodies of water during the visit. Records review, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. At 11:03 a.m. LPA observed another staff singing with one of the residents. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Medication review, medications for all residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Infection control / Emergency Disaster plan: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/02/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit. During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, May 4, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Administrator Jennifer Fulgentes arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. At approx 09:45 a.m. LPA observed four (4) resident bedrooms , which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit. LPA observed personal hygiene supplies and toiletries to be centrally stored and inaccessible in a hallway cabinet. There was one (1) staff room, which was observed to be empty during the time of the visit. The LPA inspected the kitchen/food service area. Kitchen appliances appeared clean and to be in operable condition at the time of the visit. At approx 10:00 a.m. LPA observed staff preparing food for the residents. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps were observed locked and inaccessible to residents in care. At the time of the visit, the common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in a hallway closet. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced on Aug 05, 2024. There is an office area located next to the kitchen. LPA observed facility and resident files to stored inaccessible to residents in care. Continued from 9099 All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to have a laundry area and to store, extra incontinent supplies, linen, PPE , as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. LPA did not observe any bodies of water during the visit. Records review, six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time . Last emergency disaster drill was conducted on 01/03/2025. Medications review, all medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time. Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the facility’s liability insurance. Interviews were conducted during the visit. Exit interview conducted. A copy of the report was provided to Licensethe state’s words, verbatim · CDSS document, Apr 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today. The last annual conducted at this facility was on 05/26/2023. When the LPA arrived, there were two (2) staff and four (4) residents present. LPA met with staff and the reason for the visit was explained. The Licensee Representative arrived at 9:30 a.m. Entrance interview. At 9:31 a.m., the LPA along with the Licensee Representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 9:46 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps were observed locked and inaccessible to residents in care. At 9:49 a.m., the hot water temperature was measured in the kitchen sink, and it measured 112.2 degrees Fahrenheit. COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 9:51 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 07/12/2024. LPA observed required postings throughout the common space. There is a working telephone on premises. Activities for resident use were observed in the living room. Continued on LIC 809C... Continued from LIC 809... GARAGE: The garage is attached and was inaccessible to residents in care at the time of the visit. There is one (1) additional refrigerator with perishable foods in good condition. A small locked mini refrigerator was observed with resident’s medications inaccessible to residents in care. The facility has a sufficient amount of emergency food and water. Washer and dryer were observed in the garage. Detergents and cleaning solutions were observed inside locked cabinets at the time of the visit. BACKYARD: The backyard has a shaded area with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There were two (2) gates with self-latching mechanisms. No bodies of water were noted at the time of the visit. BEDROOMS: There are four (4) resident bedrooms and one (1) staff bedroom. Two (2) bedrooms are double occupancy, and two (2) bedrooms are single occupancy. LPA observed the resident bedrooms to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. A closet in the hallway was observed with additional clean linens and towels for resident use. A locked closet in the hallway was observed with residents’ personal hygiene items inaccessible to residents in care. RESTROOMS: There are two (2) restrooms for resident use. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Hand washing signs were observed posted in the restrooms. The hot water temperature was measured in both bathrooms; the first bathroom measured 114 degrees Fahrenheit at 9:32 a.m.; and the second bathroom measured 112.8 degrees Fahrenheit at 9:39 a.m. RECORDS: Records review began at 10:05 a.m.; four (4) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All resident records were complete. Continued on LIC 809C... Continued from LIC 809C... Two (2) personnel records and Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Personnel files were complete. Administrator’s Certificate is current and valid until 06/30/2025. During today’s inspection, LPA obtained copies of Personnel Report LIC 500, Client/Resident Roster LIC 9020, and Emergency Disaster Plan LIC 610E. The Licensee Representative will be emailing copy of liability insurance to LPA no later than Monday 05/20/2024. The last disaster drill was conducted on 04/26/2024. MEDICATIONS: Medications review began at approximately 1:30 p.m.; medications are centrally stored and locked in a cabinet by the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record. Medications appeared to be given as prescribed at the time of the visit. Exit interview conducted. No citations issued at this time. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, May 18, 2024