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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608313
Report Date: 10/24/2023
Date Signed: 10/24/2023 01:52:39 PM

Document Has Been Signed on 10/24/2023 01:52 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: 4DATE:
10/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Samantha Alex - AdministratorTIME COMPLETED:
02:00 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) Tena Herrera conducted the continuation of the required annual inspection. LPA arrived unannounced and met with Samantha Alex (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 6 ambulatory elderly residents ages 60 and above.

The facility is a single-story home located in a residential area. A tour of the facility includes: 2 living rooms, dining area, kitchen, laundry room with pantry, 4 bedrooms (2 client bedrooms, 1 administrators’ bedroom, 1 administrators daughters bedroom), 3 bathrooms (2 client and 1 Staff bathroom), back yard with required shaded area and outdoor furnishing.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. However, there was not an Infection Control Plan on file or accessible for review during initial (this is being cited on 809D).


Operational Requirements: The facility has an approved fire clearance and outdoor activity area that is shaded and furnished for outdoor use.
Staffing: Administrator Certificate and qualifications were not readily available during visit, this will be cited on 809D page.
Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and training.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility does not have the required Residential Care Facility for the Elderly (RCFE) Complaint Poster this will be cited on the 809D page.
Resident Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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 7
Document Has Been Signed on 10/24/2023 01:52 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/24/2023 at 12:48 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
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 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in one client bathroom measured at 127.2 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
1
2
3
4
Administrator to create a log for the next 5 days, where water temperature is measured morning, afternoon, and evening. These readings are to be documented with time, date and reading. Water temperature to be within the required range of 105-120 degrees F.Log to start on 10/25/2023 and end on 10/29/2023. Log to be submitted via E-mail to LPA by 10/30/2023. Administrator to test water temperature regularly to ensure water temperature remains within range.
*Note Administrator lowered water heater temperature during visit*
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as LPA observed knives to be stored in unlocked pantry and medication cabinet was unlocked within the unlocked kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
1
2
3
4
Administrator to create a written plan as to where and how disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients will be stored for all staff to understand and be in compliance. This plan is to be Emailed to LPA by 11/7/23, and shall be dated and have signatures of all staff.
*Administrator locked medicine cabinet and stored knives in 2nd drawer of locked cabinet during visit*
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/24/2023 01:52 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/24/2023 at 12:48 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as Administrator could not furnish proof of Infection Control Plan during time of visits, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2023
Plan of Correction
1
2
3
4
Administrator to create and Infection Control Plan and submit plan to LPA by POC due date. This plan is to remain within facility file.
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as during initial and subsequent visits residents beds were either missing the required mattress pad or sheets, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
1
2
3
4
Administrator to place proper bedding on resident beds and submit proof of correction with photots that show all required bedding on each resident bed (not including 1 resident as it is thier preferance to not have sheets on their bed). Photos to be submitted to LPA via email by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/24/2023 01:52 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/24/2023 at 12:48 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and conversation with Administrator, the licensee did not comply with the section cited above as Administrator currently does not have a valid Administrator Certificate or required trainings, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2023
Plan of Correction
1
2
3
4
Administrator Samantha Alex to sign up for needed trainings to update Administrator Certificate. Proof of training (or enrollment) along with all other requirements found on CCL website for Administrator to be submitted via email to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/24/2023 01:52 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/24/2023 at 12:48 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as LPA toured facility on both Initial and subsequent visits and Complaint poster was not posted anywhere inside the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2023
Plan of Correction
1
2
3
4
Administrator to obtain a copy of the required Residential Care Facility for the Elderly (RCFE) Complaint Poster that is 20" x 26" and post it in a main entryway of the facility and email photos of poster in entryway to LPA by POC due date.

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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/24/2023
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
26
27
28
29
30
31
32
Physical Plant & Environment Safety: Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. During initial visit LPA observed bedding to be out of regulation, during subsequent visit bedding was still out of regulation with there being blanket and mattress pad only on one bed (missing bed sheets) [administrator stated resident does not wish to have sheets on bed] and blanket with sheet on other (missing mattress pad) [administrator stated that they use the plastic covering that comes with the mattress upon purchase as a mattress pad which is not compliant with regulation] this will be cited on 809D page. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested in resident bathroom during initial visit and was out of range (citation was issued) during subsequent visit water temperature was measured and was out of range at 127.2 degrees F the required range is 105-120 degrees F (new citation being issued today for water temperature). During subsequent visit cleaning supplies and toxins were centrally stored and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged. During initial visit it was stated that the kitchen remains locked to prevent residents from accessing medications and sharps that are stored within the kitchen, staff had indicated the only reason the kitchen was unlocked was because LPA was conducting tour, during subsequent visit LPA observed kitchen doors to be open and unlocked, LPA asked to see where sharps/knives were stored and they were stored in an unlocked cabinet as well as medication unlocked (citations will be issued on 809D).
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper training on file. Medication is properly labeled and are centrally stored in a cabinet and are in their original containers (during subsequent visit LPA observed medication cabinet to be unlocked, cited on 809D). During the initial visit, LPA reviewed 3 clients’ medication no issues were observed.
Incidental Medical & Dental: Licensee assists in arranging medical and dental services to residents in care.

(continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/24/2023
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
26
27
28
29
30
31
32
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: There are currently no resident at this facility with special health needs.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D).

Exit interview held and a copy of the report was provided to Administrator Samantha Alex.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7