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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608313
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:47:03 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2023 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230517124913
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: 4DATE:
05/23/2023
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Samantha Alex (Administrator)TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff verbally abused residents in care.
Staff physically abused residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Samantha Alex (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Resident rosters, interviewed Residents #1 to # 4 in various locations of the facility and interviewed Staff #1 and #2 in the family room.

In regards to the allegation: Staff verbally abused residents in care. Interviews with 4 of 4 Residents indicate Staff has never verbally abused them and they have never witnessed Staff verbally abusing other Residents. Interviews with 2 of 2 Staff indicate they have never verbally abused a Resident and have never witnessed Staff verbally abuse Residents.

Continue to LIC9099C....
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2023 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230517124913

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: 4DATE:
05/23/2023
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Samantha Alex (Administrator)TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unqualified staff providing care and supervision to residents.
INVESTIGATION FINDINGS:
1
2
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4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Samantha Alex (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Resident rosters, interviewed Residents #1 to # 4 in various locations of the facility and interviewed Staff #1 and #2 in the family room.

In regards to the allegation: Unqualified staff providing care and supervision to residents. Interviews with 4 of 4 Residents indicate Staff #2 is working in the facility. Interviews with 2 of 2 Staff also verified Staff #2 is working in the facility. 3 of 4 Residents interviewed also indicate Staff #3 also works in the facility and 2 of 2 Staff interviewed verified Staff #3 works at the facility. Record review indicate Staff #2 has a criminal record clearance but is not associated to the facility. Staff #3 does not have a criminal record clearance and not associated to the facility. Continue to LIC9099C....
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230517124913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 PLACE
FACILITY NUMBER: 197608313
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2023
Section Cited
CCR
87355(e)(2)
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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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Licensee shall ensure Staff #2 is not working for the facility until Staff #2 in associated to the facility and provide proof to the department.
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This requirement is not met as evidenced by: Interviews with 4 of 4 Residents indicate Staff #2 is working in the facility. Interviews with 2 of 2 Staff also verified Staff #2 is working in the facility. Record review indicate Staff #2 has a criminal record clearance but is not associated to the facility.
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Type A
05/24/2023
Section Cited
CCR
87355(e)(1)
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2
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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
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Licensee shall ensure Staff #3 is not working for the facility until Staff #3 obtained a criminal record clearance and associated to the facility and provide proof to the department.
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Department.. This requirement is not met as evidenced by: 3 of 4 Residents interviewed indicate Staff #3 works in the facility and 2 of 2 Staff interviewed verified Staff #3 works at the facility. Record review indicate Staff #3 does not have a criminal record clearance and not associated to the facility.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230517124913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 PLACE
FACILITY NUMBER: 197608313
VISIT DATE: 05/23/2023
NARRATIVE
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Based on LPA's record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC9099D.

Immediate Civil Penalties of $500 for Staff #2 and $500 for Staff #3 documented on LIC421BG.

Exit interview conducted with Samantha Alex (Administrator) and a copy of this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230517124913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 PLACE
FACILITY NUMBER: 197608313
VISIT DATE: 05/23/2023
NARRATIVE
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In regards to the allegation: Staff physically abused residents in care. Interviews with 4 of 4 Residents indicate Staff has never physically abused them and they have never witnessed Staff physically abuse other Residents. Interviews with 2 of 2 Staff indicate they have never physically abused a Resident and have never witnessed Staff physically abuse Residents.

Based on LPA's interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Samantha Alex (Administrator) and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5