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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608313
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:32:21 PM

Document Has Been Signed on 10/15/2024 03:32 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:INDIAN SUMMER PLACEFACILITY NUMBER:
197608313
ADMINISTRATOR/
DIRECTOR:		SAMANTHA ALEXFACILITY TYPE:
740
ADDRESS:1146 INDIAN SUMMER AVENUETELEPHONE:
(626) 333-4027
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Staff Henry Scott TIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Staff Henry Scott and explained the reason of the visit. The following domains were completed during the visit:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice hand washing constantly. The facility has submitted an Infection Control plan in place.

2. Operational Requirement: The facility is licensed to serve elderly residents age 60 and above. Fire clearance granted for six (6) ambulatory residents only. Currently all the residents are ambulatory. Liability Insurance documentation was not provide to LPA during the visit. Facility does not serve residents with Dementia.

3. Physical Plant and Environmental Safety: 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 of which (1) is a designated staff room, 3 bathrooms ( of which 1 is attached to the Staff room), back yard with required shaded area and outdoor furnishing. LPA inspected all three resident bedrooms: required furniture and beddings were observed as well as sufficient lighting and closet space. Bathrooms observed to be clean, sanitary and in a good working condition. The bathroom also has required grab bar and non-skid mat. The hot water temperature tested in resident bathroom is 119 degrees F which is within the Title 22 regulation. The toxic cleaning supplies are stored and inaccessible to residents. The facility has a land line telephone system. Fire alarms and C02 alarms observed. The walkway, passageway and patio are free of obstruction.

4. Staffing: The facility has sufficient staffing in the facility. Staff has updated CPR training. The administrator and care giving staff live in the facility; therefore staff is available and present overnight.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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Document Has Been Signed on 10/15/2024 03:32 PM - It Cannot Be Edited


Created By: Jose Villalobos On 10/15/2024 at 02:33 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: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was unable to provide LPA proof of liability insurance during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Facility to provide LPA proof of Liability insurance via email or FAX by POC due date.
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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Administrator Samantha Alex has an expired certificate and has not submitted packet for renewal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Administrator to schedule required administrator trainings and submit packet for administrator certificate renewal by POC due date. LPA advised to request extension if needed to complete required trainings.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 03:32 PM - It Cannot Be Edited


Created By: Jose Villalobos On 10/15/2024 at 02:33 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: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the centrally stored medication list with medication names and dosages was not udpated for (6) of (6) residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Facility to complete list of centrally stored medications and their dosages for each resident by POC due date. LPA advised that the LIC 622 can be used.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as (2) of (6) resident files were not available for LPA review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Faciltiy to gather required resident records for all residents in care and keep them in a centralized location in the facility by POC due date. Copies of resident #5 and resident #6 files can be sent via FAX to LPA as POC.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/15/2024
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5. Personnel Record Training: All the staff files are stored. The facility staff are all over 18 years old, associated with the facility and criminal background clearance. The facility administrator is Samantha Alex and her administrator certificate is expired.

6. Resident Records-Incident Reports: The resident files are centrally stored. LPA reviewed four (4) resident files and they all have the required documents which included: face sheet, pre-placement appraisal information, appraisal/needs and service plan, admission agreement, updated physician report and TB test, ambulatory status and medication list. Two (2) Resident files were not present for review.

7.Residents' Right : The facility has all the required postings. The facility also has internet service shall provide at least one internet access device for resident use to face time with their families or entertainment.

8. Planned Activities: The facility does have sufficient space to accommodate both indoor and outdoor activities

9. Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable. All the food are stored probably. No residents are on modified diet that prescribed by the doctor.

10. Incident Medical and Dental: The resident medication are centrally stored and locked in the kitchen cabinet. LPA inspected all six (6) residents medications on hand. Centrally stored medication list for (2) of (6) residents were not completed to match prescription orders. Administrator will also provide medical and dental transportation if needed.

11. Disaster Preparedness: The facility has a disaster plan in place. The facility has two alternative temporary shelter location. Facility was provided notice to update the disaster plan to the updated form provide by the department.

12. Residents with Special Health Needs: There is (1) resident with home health services. LPA reviewed and observed the home health file. There are no residents on hospice. No resident is under restricted health condition or prohibited health condition.

Per the completion of the Inspection Tool, deficiencies are being cited for todays visit. Please see attached 809-D pages. Appeal rights discussed and provided. Exit Interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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