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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608313
Report Date: 08/19/2021
Date Signed: 08/19/2021 04:20:08 PM

Document Has Been Signed on 08/19/2021 04:20 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:INDIAN SUMMER PLACEFACILITY NUMBER:
197608313
ADMINISTRATOR:SAMIEPER DUQUEFACILITY TYPE:
740
ADDRESS:1146 INDIAN SUMMER AVENUETELEPHONE:
(626) 333-4027
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 5DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Samantha Alex, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced annual required visit using the Infection Control domain. LPA met with Administrator, Samantha Alex, and explained the purpose of the visit. The facility is licensed for 6 ambulatory residents age 60 and over. There are currently 5 ambulatory residents at the home.

LPA Chan toured the facility with the Administrator and inspected/observed the following:
* There are 4 bedrooms and 3 bathrooms (3 bedrooms are for residents and 1 for the Administrator). Each bedroom is equipped with the required furniture.
* There are 2 living rooms, a kitchen, and a spacious backyard with shaded area with a table and chairs.
* Food supplies were observed for 2-day perishable and a week of non-perishable.
* Some signs are posted regarding the Covid-19 (Coronavirus).
* There are no items obstructing the entry or walkway.
* Knives and disinfectants are inaccessible to residents.
* Medication was reviewed for 3 residents and medications match the physician's orders.
The following deficiencies were observed today:
* The hot water temperature was measured at 134.2 degree F, which is over the required range of 105 – 120 degree F.
* Staff #1 does not have fingerprint clearance nor associated to the facility.

The deficiencies are documented on the LIC809D. An exit interview was conducted. A copy of this report, LIC809D, and the appeal rights were given to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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 08/19/2021 04:20 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Cynthia D Chan On 08/19/2021 at 03:20 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INDIAN SUMMER PLACE
FACILITY NUMBER: 197608313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for Staff #1 who does not have clearance nor associated to the facility and does not which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/20/2021
Plan of Correction
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The licensee shall ensure that Staff #1 is not working on the premises until staff obtains background clearance and is associated to the facility and a statement shall be provided to the LPA acknowledging it by POC due date 8/20/21.
**A civil penalty is being issued for this deficiency.**
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


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 in that the water temperature was measured at 134.2 degree F which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/20/2021
Plan of Correction
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The licensee shall ensure that the hot water temperature is within the required range of 105-120 degrees F at all times. The licensee shall measure and document the hot water temperature tested at different times and submit to LPA by 8/20/21.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
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