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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204221
Report Date: 04/15/2025
Date Signed: 04/16/2025 08:06:37 AM

Document Has Been Signed on 04/16/2025 08:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SUMMER SPRINGS BOARD & CAREFACILITY NUMBER:
157204221
ADMINISTRATOR/
DIRECTOR:		SOCORRO TELMOFACILITY TYPE:
740
ADDRESS:6112 SUMMER SPRINGS DRIVETELEPHONE:
(661) 397-0416
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 6CENSUS: 6DATE:
04/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee/ Administrator Socorro "Ann" Telmo. TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 04/15/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and met with Licensee/ Administrator Socorro “Ann” Telmo. LPA toured facility with A1. All six residents were present during the inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Medications were observed locked in kitchen shelf. Residents’ MARS and Centrally Stored Medication Records were reviewed. Medications were checked. Fire extinguisher was observed with a service date of: 03/18/25. Chemicals observed locked under kitchen sink. An adequate supply of perishable and non-perishable food was observed. Freezer temperature maintained at -16 degree F and refrigerator temperature maintained at 40 degrees F. Knives observed locked in kitchen drawer. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested range at 116.3 degrees F in hall bathroom and 117.1 degrees F in master bathroom. Extra linens were observed. Outside of facility toured and observed free of debris. Side gate was self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of staff files were reviewed to have all required documents.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 04/21/25. The following updated forms were requested: Lic 308, Lic 500, Lic 610D, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mai Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/16/2025 08:06 AM - It Cannot Be Edited


Created By: Mai Yang On 04/15/2025 at 01:20 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: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observations, records reviewed, and interviews conducted, staff administered R2’s Oxybutynin 5 mg on 04/05/25 and did not record in the resident’s MARs, which poses/ posed a potential health and safety risk for the person in care.
POC Due Date: 04/16/2025
Plan of Correction
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S1 will be retrained in in-service training on proper administering medication and documentation. Licensee will submit documentation of training topics and staff attendance to CCL by POC due date 04/16/25.
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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2025 08:06 AM - It Cannot Be Edited


Created By: Mai Yang On 04/15/2025 at 01:26 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: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state, and local authorities. Good in damaged containers shall not be accepted, used, or retained.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation, expired food was observed, which poses/posed an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 04/16/2025
Plan of Correction
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Licensee immediately disposed expired food. POC cleared during visit.
Type A
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on records review and observation, staff did not administer R1’s Aspirin 81 mg and Simvastatin 20mg medication and did not administer R2’s medication Aspirin 81mg and Melatonin 10 mg as directed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 04/16/2025
Plan of Correction
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Licensee agree to write statement of steps facility will take to ensure regulations is met. Statement will be submitted to Fresno CCL by POC due date 04/16/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mai Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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