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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608313
Report Date: 10/03/2022
Date Signed: 10/03/2022 02:23:09 PM

Document Has Been Signed on 10/03/2022 02:23 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:SAMANTHA ALEXFACILITY TYPE:
740
ADDRESS:1146 INDIAN SUMMER AVENUETELEPHONE:
(626) 333-4027
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 6DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Samantha Alex (Administrator)TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Samantha Alex (Administrator) and explained the purpose of the visit. FACILITY LICENSED TO SERVE ELDERLY RESIDENTS AGE 60 AND ABOVE. FIRE CLEARANCE APPROVED FOR 6 AMBULATORY RESIDENTS.

During today’s visit, LPA observed the following: Physical Plant and Environmental Safety: Sufficient lighting, non-skid maps in bathroom, comfortable temperature, Hot water temperature measured at 136.4 degree F in the hallway bathroom. LPA observed 2 live cockroaches in the Resident records. Operational Requirements: Facility has an approved fire clearance. Staffing: There is sufficient staff, the administrator is on the premises during normal business hours. Personnel Records - Training: Staff #1, #2 did not have current first aid/CPR training and LPA did not observed a health screening for Staff #2. Resident Records/Incident Reports: Admission agreement, medical assessment and appraisal observed. Resident Rights/Information: Complaint poster (PUB 475) posted on wall next to the garage entrance, resident's personal rights in file. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities, furnished areas is provided for relaxation of residents and entertaining friends and relatives. Food Services: Perishable foods are stored in covered containers, toxins are stored separate from foods, kitchen is kept clean. Resident with Special Health Needs: Hospice care plan is current, items that can constitute a danger is inaccessible to residents. Incidental Medical and Dental: Licensee provide assistance in meeting medical and dental needs for residents, all centrally stored medications is labeled and maintained in compliance with state and federal law.

Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.



An exit interview was conducted and a copy of this report and appeal rights provided to Samantha Alex.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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 4
Document Has Been Signed on 10/03/2022 02:23 PM - It Cannot Be Edited


Created By: Kruz Long On 10/03/2022 at 01:31 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: 10/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: Hot water temperature measured at 136.4 degree F in the hallway bathroom.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2022
Plan of Correction
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Licensee shall immediately adjust water temperature to measure within Title 22 guidelines.

Note: Water temperature was adjust at time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/03/2022 02:23 PM - It Cannot Be Edited


Created By: Kruz Long On 10/03/2022 at 01:39 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: 10/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by: LPA observed 2 live cockroaches in the Resident records
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited abovewhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2022
Plan of Correction
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Licensee shall obtain pest control services and provide proof to the department by the POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/03/2022 02:23 PM - It Cannot Be Edited


Created By: Kruz Long On 10/03/2022 at 01:58 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: 10/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)


This requirement is not met as evidenced by: Staff #1, #2 did not have current first aid/CPR training.
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2022
Plan of Correction
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2
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4
Licensee shall obtain current first aid/CPR training for Stafff #1, #2 and Staff who does not have current first aid/CPR training and provide proof to the department by the POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4