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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608313
Report Date: 11/03/2023
Date Signed: 11/03/2023 09:57:52 AM

Document Has Been Signed on 11/03/2023 09:57 AM - 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:
11/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Samantha Alex - AdministratorTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to ensure that deficiencies cited on 10/24/23 have been corrected. LPA met with Administrator Samantha Alex and explained the purpose for the visit.

87303(e)(2): on 10/13/23 LPA conducted the initial annual visit and observed water temperature in clients restrooms to be 128.6-129.5 degrees F, which was outside of the required range of 105-120 degrees F. During subsequent visit on 10/24/23 LPA observed water temperature in 1 out of 2 client restrooms to be at 127.2 degrees F, on both visits facility was cited Maintenance and Operation: 87303(e)(2). During todays visit LPA tested both client restrooms water temperature and they measured at 137.2 and 140.5 degrees F, Administrator lowered water temperature during visit. Civil penalty is being assessed.

87309(a): on 10/13/23 LPA conducted the initial annual visit and observed cleaning cleaning solutions in an unlocked cabinet under client bathroom sink, on subsequent visit 10/24/23 LPA observed knives to be stored in unlocked pantry and medication cabinet was unlocked within the unlocked kitchen. On both visits facility was cited Storage Space: 87309(a). During todays visit LPA toured facility, no cleaning solutions were found under clients restroom sinks, medicine cabinet was also observed and was locked. Kitchen was observed to have cleaning solutions stored under kitchen sink and were unlocked (administrator stated that the lock was lost), knives were observed in a separate cabinet and were also unlocked, during visit Administratror Samantha Alex locked both cleaning supply and knife storage cabinets. Civil penalty is being assessed.

Exit Interview conducted and copy of the report and appeal right was provided to Administrator Samantha Alex.

Administrator refused to sign LIC421FC's and 809.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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