<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608232
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:32:49 PM

Document Has Been Signed on 03/14/2025 03:32 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SUMMER HOUSE AT LADERA HEIGHTSFACILITY NUMBER:
197608232
ADMINISTRATOR/
DIRECTOR:		SHERRYL RAFOLSFACILITY TYPE:
740
ADDRESS:6108 DAMASK AVENUETELEPHONE:
(323) 792-4105
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 4CENSUS: 4DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Marilyn NeryTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/14/2025 Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the CARE Inspection tool. LPA met with Caregiver, Marilyn Nery, and the purpose of today’s visit was explained. The facility is licensed to serve four (4) non-ambulatory residents, one (1) of which may be bedridden in room two (2) with an approved hospice waiver for two (2) residents. Currently there are four (4) residents residing in the facility.

Physical Plant/Structure- The facility is a single-story home in a residential neighborhood. The facility consists of three (3) bedrooms, one (1) staff room, two (2) resident bathroom, one (1) staff/visitor bathroom, living room area, dining area, kitchen with a laundry area. All walkways outside the facility were observed clean, clear, and free of obstructions, hazards, and debris. LPA did not observe any bodies of water on the premises.

Bedrooms- LPA inspected all resident bedrooms and observed they had the required furniture. All rooms had bed(s), dresser, nightstand, storage space for resident’s personal belongings, chair, and ample lighting. LPA observed all beds had the required linens including mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens stored in resident’s rooms.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232
VISIT DATE: 03/14/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Bathrooms- LPA inspected all bathrooms in the facility and observed them to be operational and within Title 22 regulations. LPA observed shower chairs and non-skid mats in the shower. The safety handrails are secured. LPA observed an ample supply of hygiene products for residents secured and inaccessible to residents. The department observed an ample supply of towels, hand towels, and wash clothes in good repair. The water temperature measured 110-degrees, 110.9-degrees and 112.6-degrees Fahrenheit.

Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed all appliances were operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. LPA observed cleaning supplies secured in a locked cabinet. LPA observed sharps and knives secured in a locked drawer in the kitchen. The water temperature measured 112.6-degree Fahrenheit.

Common Areas LPA observed in the living room a large couch and four (4) chairs to accommodate all residents. LPA observed a fireplace screened and inaccessible to residents. The dining room has a large table with chairs to accommodate residents. LPA observe games and activities in resident’s rooms. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All rooms were observed with ample lighting. The facility was maintained at a comfortable temperature.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232
VISIT DATE: 03/14/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Files LPA reviewed four (4) resident files and found they did not contain all the required documents. The department reviewed the Administrators and two (2) staff files and found they contained most of the required documents and certification. LPA did not observe training logs for 2024 or 2025. During the visit, LPA informed the Administrator licensing fees are due this month (March 2025) and provided the PIN.

Medication LPA observed all Centrally Stored Medications secured in a locked closet in the hall. All medications were observed in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for four (4) residents. LPA observed four (4) out of four (4) resident’s MARs and medication are consistent with properly documented records.

Infection Control During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station and visitor log upon entry. LPA observed it has hand sanitizer, masks, gloves, and a thermometer available. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated infection control signs were posted throughout the facility.

Safety LPA observed smoke detectors and carbon monoxide were operable. LPA observed a fully charged fire extinguisher with a receipt from 2024. The last

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232
VISIT DATE: 03/14/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
emergency drill was conducted on 09/27/24. The facility has a working telephone. LPA was emailed a copy of the liability insurance. LPA inspected the First Aid Kit and found it contained the required items and a current manual. There are no firearms or ammunition stored on the premises.

Deficiencies are cited on the LIC809-D page.

An exit interview was conducted with Caregiver, Marilyn Nary, and a copy of this report and the Appeals Rights were provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/14/2025 03:32 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 03/14/2025 at 02:40 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: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview,and record review, the licensee did not comply with the section cited above in two (2) out of two (2) staff, S3 and S4, did not have training records for 2024 or 2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
1
2
3
4
Licensee will conducted or arrange in-services and training for staff S3 and S4. Licensee will email LPA logs of the in-services or trainings by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/14/2025 03:32 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 03/14/2025 at 02:40 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: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above Resident R2 did not have not have an Admission Agreement on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
1
2
3
4
Licensee will review Resident R1 - R4's file and ensure they have the required documents. Licensee will email LPA a copy of Admission Agreement for R2, and pre-appraisal.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/14/2025 03:32 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 03/14/2025 at 02:40 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: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above LPA obseved the last documented emergency drill was conducted on 09/27/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
1
2
3
4
Licensee will schedule an emergency drill and email documenation to LPA before the POC due date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, andrecord review, the licensee did not comply with the section cited above, LPA reviewed the LIC610-E posted and obsered it was last updated on 08/05/11, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
1
2
3
4
Licensee will review and update LIC610-E form and email LPA an updated copy by POC date.
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:Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 7 of 7