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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608232
Report Date: 03/15/2022
Date Signed: 03/15/2022 04:09:41 PM

Document Has Been Signed on 03/15/2022 04:09 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SUMMER HOUSE AT LADERA HEIGHTSFACILITY NUMBER:
197608232
ADMINISTRATOR:SHERRYL RAFOLSFACILITY TYPE:
740
ADDRESS:6108 DAMASK AVENUETELEPHONE:
(323) 792-4105
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 4CENSUS: 4DATE:
03/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:caregiver - Chris GaytosTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Don Senaha conducted a Case Management as part of the annual review required to cite the facility for deficiencies. Annual review was conducted on 3/15/22 and deficiencies were cited on 3/15/22. There were five (5) deficiencies cited during the visit.

LPA discussed on the phone with Administrator Mark Loo all deficiencies and caregiver Chris Gaytos was ok to sign per Mark.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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 03/15/2022 04:09 PM - It Cannot Be Edited


Created By: Don Senaha On 03/15/2022 at 12:20 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2022
Section Cited
CCR
87303(e)(2)

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87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained to automatically regulat the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F and not more than 120 degrees F.
This requirement is not met as evidenced by:
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Per Administrator will adjust water and send pictures of the water temperature via email or text to LPA by 3/17/2022.
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Based on observation by LPA, the water tempeerature in the kitchen sink measured 130.5 F at 10:06am and 130.8 F at 10:18am in the shared bedroom bathroom which poses an immediate health and
safety risk to persons in care.
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Type A
03/17/2022
Section Cited
CCR87309(a)

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87309(a) Storage Space. 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:
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Caregiver immediately moved the disinfectants and cleaning solutions to a locked cabinet.
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Based on observation by LPA, there was bleach and laundry detergent on an open shelf next to the clients shared room which poses an immediate health and
safety risk to persons in care.
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022


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Document Has Been Signed on 03/15/2022 04:09 PM - It Cannot Be Edited


Created By: Don Senaha On 03/15/2022 at 12:45 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
Section Cited
CCR
87303(a)

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87303(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, employees
and visitors.
This requirement is not met as evidenced by:
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Per Administrator will fix or replace the dresser by the POC date.
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Based on observation, LPA observed a resident dresser on R4 room without handles to open the drawer at the facility which poses a potential health and safety risk to persons in care.
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Type B
03/29/2022
Section Cited
CCR87506(a)

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87506(a) Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and licensing agency staff.
This requirement is not met as evidenced by:
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Administrator will do an in-service training and send me signed logs of records being maintained including the MAR.
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LPA observed the resident record of the Medication Administration Records (MAR) were not up to date and maintained correctly which poses a potential health ad safety risk to persons in care.
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022


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Document Has Been Signed on 03/15/2022 04:09 PM - It Cannot Be Edited


Created By: Don Senaha On 03/15/2022 at 12:57 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2022
Section Cited
CCR
80072(a)(2)

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Personal Rights
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by:
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Per Administrator will move the resident R1 back to her room in the facility by 3/17/22.
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Based on observation by LPA, resident R1 was in the converted garage room shared with a staff which poses an immediate health and
safety risk to persons in care.
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022


LIC809 (FAS) - (06/04)
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