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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204221
Report Date: 05/12/2022
Date Signed: 05/12/2022 10:06:46 PM


Document Has Been Signed on 05/12/2022 10:06 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SUMMER SPRINGS BOARD & CAREFACILITY NUMBER:
157204221
ADMINISTRATOR:SOCORRO TELMOFACILITY TYPE:
740
ADDRESS:6112 SUMMER SPRINGS DRIVETELEPHONE:
(661) 397-0416
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:6CENSUS: 6DATE:
05/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
07:00 PM
MET WITH:Manager-Member /Administrator (Admin) Socorro "Ann" Telmo; Manager-Member (MM) Dio Telmo; TIME COMPLETED:
10:30 PM
NARRATIVE
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A Case Management visit was conducted on the date & during the times indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA met with Manager-Member /Administrator (Admin) Socorro "Ann" Telmo & Manager-Member (MM) Dio Telmo.

During a complaint investigation, it was determined that an incident of resident being sent to hospital was not reported to the Department.

Deficiency issued.
Exit interview conducted with Admin & MM. Report provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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 05/12/2022 10:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2022
Section Cited

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Reporting Requirements - A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
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Incident of resident being sent to hospital was not reported to the Department.
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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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2