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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608313
Report Date: 08/24/2023
Date Signed: 08/29/2023 09:34:50 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
04/14/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230414160419
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:
08/24/2023
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Samantha AlexTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff are not answering facility phone.
Staff abandoned resident.
INVESTIGATION FINDINGS:
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**THIS IS A CORRECTED VERSION OF COMPLAINT REPORT DATED 8/17/23.**
Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit to deliver findings on 08/17/23 regarding the above allegation(s). LPA Ramirez was met by Staff #1 (S1) and Administrator Samantha Alex and explained the purpose of the visit. S1 led LPA Ramirez on tour of facility. LPA Ramirez initiated Case Management-Deficiencies visit on 8/17/23 because of facility tour.

The investigation consisted of the following: Initial complaint investigation was conducted on 4/18/23 by LPA Tena Herrera and needs further investigation was required. On 8/17/23, LPA Ramirez requested and obtained copies of Resident Roster, Staff #1-2 interviews (S1- S2), Resident #1 interviews (R1), Witness #1 – 2 Interviews (W1- W2), R1 Face sheet, R1 Discharge Summary/Comprehensive Assessment dated 7/24/23, Notice of Proposed Transfer/Discharge signed 7/19/23, Post Discharge Plan of Care signed 7/24/23, and other pertinent documents regarding this complaint.

See 9099-C for continuation.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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 2
Control Number 28-AS-20230414160419
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 PLACE
FACILITY NUMBER: 197608313
VISIT DATE: 08/24/2023
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff are not answering facility phone- It is alleged that staff did not answer facility phone on or around 4/15/23. Two (2) out of two (2) staff interviewed deny this allegation. On 8/15/23 at 11:16 am, LPA Ramirez dialed facility phone number and was greeted by unknown staff. During today’s visit, LPA Ramirez observed facility phone to be operational. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Staff abandoned resident- It alleged staff abandoned R1 at hospital on or around 4/15/23. Two (2) out of two (2) staff interviewed deny this allegation. Interview with W2 revealed that W2 is R1 current physician and has been under W2’s care for the past 10 years. W2 revealed to LPA Ramirez that W2 ordered R1 to be sent to a rehabilitation facility on 4/15/23 and gave those order to hospital staff on 4/15/23. According to W2, R1 required a higher level of care at that time and could not go back to the facility. Admission Record from Coast Care Convalescent Care dated 7/12/23, indicates R1 was admitted into their facility on 4/15/23. Notice of Proposed Transfer/Discharge from Coast Care Convalescent Care dated 7/19/23, indicates R1 will be discharged back to Indian Summer Place on 7/24/23. LPA Ramirez interviewed and observed R1 in the facility during visit. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Administrator Samantha Alex. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2