157204221-4-27-2023-24-AS-SDOE-CRB4PE-20230427191636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157204221
Report Date: 04/27/2023
Date Signed: 04/27/2023 07:16:57 PM

Document Has Been Signed on 04/27/2023 07:16 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 & CARE		FACILITY NUMBER:	157204221
ADMINISTRATOR:	SOCORRO TELMO		FACILITY TYPE:	740
ADDRESS:	6112 SUMMER SPRINGS DRIVE		TELEPHONE:	(661) 397-0416
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93313
CAPACITY:	6	CENSUS: 6	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator Socorro Telmo		TIME COMPLETED:	07:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Socorro Telmo. LPA disclosed the purpose of the visit and was granted entry into the facility by Staff Benjamin Wandasan.

A tour of the facility was conducted with the Administrator.

LPA Doucette observed 4 bedrooms in the facility. While touring the facility, LPA observed an added staff bedroom/office which was not on the facility sketch and was not fire cleared. Facility did not notify licensing of construction or obtain a building permit. Hot water temperature was measured 118.2 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cart and locked refrigerator. Cleaning supplies were in a locked cabinet under the kitchen and bathroom sinks. Smoke detectors and carbon monoxide detectors were checked and operating. Facility has a pull station fire alarm.

Resident, medication, and staff records were reviewed. R2's centrally stored log was reviewed and errors were observed. R1's records were reviewed and it was found that R1 self administers injections however facility did not have a sharps container to dispose of needles/syringes. Sharps were disposed of in an open trash can next to R1's bed. R3 requires a restricted health care plan. Administrator did notify licensing of R3's restricted health condition and facility did not have a care plan for R3 at the facility. Staff did not have current first aid and CPR training. Staff did not have updated training for annual hours required, hospice training for hospice residents and training for restricted health care plan.

Deficiencies were observed and will be cited under Title 22, Division 6. See LIC 809D and LIC 9102. Civil Penalties were issued.

An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were discussed and left with the Administrator, Socorro Telmo, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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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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: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 by adding a staff room/office which was previously the garage, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit facility sketch adding the staff room/office, LIC200 and LIC9054 by 04/28/23. Licensee agree to submit fire clearance for additional room by 5/31/23. Civil Penalties were issued.

Type A

Section Cited

CCR

87303(f)(2)

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview, the licensee did not comply with the section cited above by disposing used needles/syringes in an uncovered trash can in R1's room, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to purchase a sharps container to dispose of all sharps including needles and syringes. POC cleared 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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 07:16 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: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not obtaining a building permit to construct a staff bedroom/office in the garage, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written understanding of the regulation by POC due date 05/31/23.

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit CPR/First Training for all staff by POC due date 05/31/23.

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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 07:16 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: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.696(a)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Licensee agrees to provide staff training for all staff to meet this regulation and submit training agenda that includes training, trainer and hours trained and sign in sheet by 5/31/23

Type B

Section Cited

HSC

1569.696(a)(1)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Licensee agrees to provide staff training to all staff to meet this regulation and submit training agenda that includes training, trainer and hours trained and sign in sheet by 5/31/23.

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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 07:16 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: 04/27/2023

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 record which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written understanding of this regulation and how it will be met by POC due date 05/31/23.

Type B

Section Cited

CCR

87616(b)(1)

Exceptions for Health Conditions

(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit to licensing a restricted health care plan R3 by POC due date 05/31/23.

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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 07:16 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: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(b)(4)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit Hospice Care Plan that meets this reglulation for R2 and submit to licensing by POC due date 05/31/23.

Type B

Section Cited

CCR

87633(b)(6)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit staff training for staff that are providing care for 3 hospice residents that meet the above regulation. Licensee agrees to submit training for staff by POC due date 5/31/23.

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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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