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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608313
Report Date: 08/17/2023
Date Signed: 08/17/2023 05:11:07 PM

Document Has Been Signed on 08/17/2023 05:11 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
GREATER LA AC/SC, 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: 5DATE:
08/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Samantha AlexTIME COMPLETED:
04:45 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
Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 8/17/23 at 9 am, stemming from subsequent complaint investigation on 8/17/23. LPA Ramirez conducted tour of facility and records review in relation to complaint investigation. Deficiencies are being cited as a direct result of facility tour and observations made.

Case Management-Deficiencies findings:

· During medical record review of Resident #1 (R1) facility file, two (2) small insects that appeared to be “roaches” were observed crawling in between documents in R1’s file. Annual inspection conducted on 10/03/22, by LPA Long, resulted in deficiencies being cited. Facility was cited for violation of CCR- Maintenance and Operation 87303(a) “The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.” Plan of Correction (POC) indicated “Licensee shall obtain pest control services and provide proof to the department by POC due date of 10/17/22.” The facility submitted proof to clear POC on 10/16/22. Facility has failed maintain professional pest control services since 10/22. This is evidence by roaches still being observed in facility files and the facility’s failure to provide LPA Ramirez proof of continued professional pest control services at the facility. LPA Ramirez is issuing Civil Penalty Assessment for Repeat Violations in the amount of $250 for repeat violation within a 12 month period. Thereafter, a civil penalty of $100 a day will be assessed until the violation is corrected.



Exit interview conducted with Administrator Samantha Alex. Deficiency and civil penalty were cited. A copy of this report and 809-D, LIC 421FC and appeals rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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 2
Document Has Been Signed on 08/17/2023 05:11 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 08/17/2023 at 02:56 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee will contract with professional pest control services. Licensee will submit contract to LPA Ramirez by 8/31/23. Licensee will maintain monthly professional pest control services until insects are eradicated from the facility.
8
9
10
11
12
13
14
2 live small insects (roaches) were observed crawling in between R1's facility file. Facility was previously cited on 10/3/22 for same violation.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2