Autumn Manor LLC #3

Type of visit: Required - 1 Year

At 8:30 A.M. Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff, Lydia Palaroan Baracena, and explained the reason for the visit. At 9:13 A.M. Licensee Maria Mendez and back-up Administrator, Christopher Fulgentes, arrived and the reason of the visit was explained. LPA and staff 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. The following was observed: During the physical plant tour, the LPA observed five (5) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The shared bathrooms were clean and sanitary and in operating condition with grab bars and slip resistant 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 locked and inaccessible to residents in care. The LPA inspected the kitchen/food service area. Kitchen appliances appeared clean and to be 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. Continued on LIC 809-C Continued from LIC 809-C At the time of the visit, the common area furniture's were observed to be in good condition. LPA observed a fireplace properly screened. A sufficient supply of clean linen and towels were observed stored in a hallway closet. The facility maintained a temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed that the facility is equipped with a fire sprinkler system throughout the premises. The Licensee was unable to provide current system inspection report. Technical Advice (TA) issued. Also, LPA observed multiple fully charged fire extinguishers, they were last serviced 08/11/2025. There is an office area located next to the kitchen. LPA observed resident files 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 emergency food, emergency water, 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 the main gate and the side gates with clear passageways clear of obstruction. LPA did not observe any bodies of water during the visit. Records review, three (3) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. 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. Emergency disaster drills are conducted every three (3) months. Continued on LIC 809-C Continued from LIC 809-C Medications review, all medications including PRNs were labeled, stored and inaccessible to residents in care. LPA observed that medication was being pre-popped in advance of administration. During today’s visit LPA informed the licensee and designee that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. Technical Violation (TV) issued. Furthermore, LPA observed a discrepancy between the Resident #1’s (R1’s) physician’s order, medication label, and the facility’s medication records. The Sertraline 50 mg Oral Tab bottle, the hospice Plan of Care dated on 03/06/2026, and a current medication list, dated 07/21/2026, indicated that R1 is to take one (1) and one-half (1/2) tablets by mouth every morning. However, staff confirmed the R1 has been receiving one tablet by mouth every morning, consistent with the Centrally Stored Medication and Destruction Log and Medication Administration Record (MAR) record. This reflects that medication has not being administered in accordance with the physician’s prescribed order. Infection control: 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 they pertain to infection control and emergency disaster plan are adequate. LPA reviewed the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, facility’s liability insurance. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 21, 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. Licensee Marie 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 09:45 a.m. LPA observed five (5) 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 and inaccessible to residents in care 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 09:55 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 08/05/2024. There is an office area located next to the kitchen. LPA observed facility and resident files to stored inaccessible to residents in care. 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, emergency food, 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 one (1) self-latching gate with clear passageways clear of obstruction. LPA did not observe any bodies of water during the visit. Records review, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Four (4) 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 07/04/2025. 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. LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, facility’s liability insurance and Dementia Plan of Operation. Interviews were conducted during the visit. Exit interview conducted. A copy of the report was provided to Licensethe state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Trevor Byrne, Angela Barutyan, and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 09:38AM. LPAs met with staff and the reason for the visit was explained. Administrator Jennifer Fulgentes arrived at 09:44AM. Entrance interview conducted. Beginning at 09:41AM, the LPAs, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguisher was fully charged and serviced on 07/12/2023. Combination smoke and carbon monoxide detectors were tested at 10:06AM and all were functional at the time of the visit. No fire clearance concerns were observed. BEDROOMS: There are 5 (five) total bedrooms in the facility; 2 (two) are designated as shared rooms, 2 (two) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Room #4, which belongs to Resident #1 (R1) was observed to have full bed rails. Room #5, belonging to Resident #2 (R2) contained a fireplace that was observed to be inaccessible to residents, the resident’s bed was also observed to have full bed rails. BATHROOMS: There are 2 (two) bathrooms for resident use. Restrooms were observed to contain nonskid mats. Grab bars were observed in the bathrooms. Water temperature was measured in bathroom 1 (one) at 09:45AM and was observed to be 118.8F. Water temperature was measured in bathroom 2 (two) at 09:52AM and was observed to be 115.2F. Both bathrooms were measured within the required range. Report Continued on LIC 809-C COMMON AREAS: This includes the living room. LPAs observed common area to be clean and properly furnished at the time of the visit. Exit doors contain alarms and were functional at the time of the visit. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. All gates were observed to be self-latching. There were no bodies of water on the premises. KITCHEN/GARAGE: The LPAs observed the garage to contain locked cleaning supplies, emergency food, additional refrigerator/food storage, as well as supplies and laundry machines. 3 (three) bags of beans designated as emergency food were observed to be expired. Expired food was disposed of at 10:03AM. Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies are located in a locked under-sink cabinet. Knives were stored securely in a locked drawer. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs 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 plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 04/15/2024. RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 3 (three) staff files observed contained all documents. 2 (two) resident files were reviewed and both contained all documents. MEDICATION REVIEW: Medications for 2 (two) residents were observed. At 11:48AM, R2’s medication bin was observed to contain unlabeled Albuterol Sul quantity 2. R2 has PRN prescribed however it has not been started yet. Staff disposed of unlabeled medication at time of visit. INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and attempted to interview 2 (two) residents both of which were non-verbal. During today's visit, LPAs obtained a copies of the personnel report (LIC500), client roster (LIC9020), and the facility's liability insurance. Report Continued on LIC 809-C Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 1, 2024

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.