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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204221
Report Date: 04/26/2022
Date Signed: 05/04/2022 04:04:21 PM

Document Has Been Signed on 05/04/2022 04:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SUMMER SPRINGS BOARD & CAREFACILITY NUMBER:
157204221
ADMINISTRATOR:SOCORRO TELMOFACILITY TYPE:
740
ADDRESS:6112 SUMMER SPRINGS DRIVETELEPHONE:
(661) 397-0416
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 6CENSUS: 5DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Licensee/Administrator Socorro Telmo (Ann)
TIME COMPLETED:
04:45 PM
NARRATIVE
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On 4/26/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Licensee/Administrator Socorro Telmo (Ann)

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one
entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other
various Covid-19 related signs were observed in the common areas. Facility staff observed with facecoverings.

All pathways, entrances and exits were clear from obstructions. Fire extinguisher was serviced on 3/3/2022. LPA toured bedrooms with adequate furnishings. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA observed a 30-day supply of PPE. LPA checked residents' medication and observed a 30-day supply. Laundry area was observed unlocked with laundry detergent, bleach, and cleaning supplies. Staff files were reviewed for good health. It was verified that there is at least one staff on duty who is CPR certified. LPA did not observe updated emergency contact information for Resident’s.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/03/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC
309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel
Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Staff. As a COVID-19 precautionary measure, a copy of this report will be provided via email. Report signed on-site by Administrator.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2022 04:04 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 04/26/2022 at 04:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed a bleach bottle, laundry soap and other cleaning chemical bottles stored in an unlocked laundry cabinet in the laundry room accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care..
POC Due Date: 04/26/2022
Plan of Correction
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Administrator immediately removed the items to a locked cabinet. POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Brenda White
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022


LIC809 (FAS) - (06/04)
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