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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608232
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:04:30 PM

Document Has Been Signed on 07/27/2023 02:04 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
EL SEGUNDO, 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: DATE:
07/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Chris GaytosTIME COMPLETED:
02:10 PM
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On 7/27/23, Licensing Program Analyst (LPA) Felisa Shirley arrived to follow-up on deficiencies issued during visit on 7/21/23. LPA was met by staff Chris Gaytos, and the purpose of today’s visit was explained.

The following deficiencies were observed and cited for on 7/21/23:

-At 09:55 am LPA took hot water temperate in facility kitchen and noted that it was 120.8 F.
-At 09:57 am LPA observed that cabinet in kitchen which held medication was not locked.
-At 10:06 am LPA observed a bottle of Lysol under bathroom sink, cabinet did not have a lock.
-At 10:06 am LPA observed Lysol and Clorox wipes located on rack above toilet in bathroom accessible to residents.

During today’s visit, LPA observed the following:

-at 11:15 am LPA observed that the water measured at 124.3.
-at 11:17 am LPA observed that the locks on medication cabinet where on the cabinet, but not engaged.

LPA observed that the bottle of Lysol was removed from cabinet under the bathroom sink. LPA also observed that the bottle of Lysol and Clorox wipes were removed from the rack above the toilet in the bathroom. A Plan of Correction letter is being issued.

As these citations have not been cleared, civil penalties will be issued for failure to correct.

An exit interview was conducted and a copy of this report, civil penalties and appeal rights were provided to caregiver Chris Gaytos.


SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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