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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608011
Report Date: 09/13/2022
Date Signed: 09/14/2022 05:34:12 PM


Document Has Been Signed on 09/14/2022 05:34 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 DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:SUMMERWIND MANORFACILITY NUMBER:
197608011
ADMINISTRATOR:JOSEPH SOLFACILITY TYPE:
740
ADDRESS:3117 W. CARSON STREETTELEPHONE:
(310) 328-1671
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 6DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:JEMIMAH MEJIATIME COMPLETED:
03:30 PM
NARRATIVE
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On 09/13/2022 at 11:30 am, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced Required – 1 Year Inspection and met with two caregiver Michael San Agustin (S1) and Eyla Aguil (S2). LPA explained the purpose of the visit. Staff Jemimah Mejia arrived shortly after and assisted LPA with the visit. There were six (6) clients and three (3) staff present in the facility during this inspection.

Facility is licensed licensed to serve clients age 60 and over, five (5) non-ambulatory and one (1) may be bedridden. Approved Hospice Waiver for four (4). The Annual Licensing Fees are current. Rooms "A" only as approved for one bedridden. LPA observed a bedridden resident sleeping in bedroom B (or #2).



The facility is a single story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, living room, kitchen, dining room, family room/office, shaded area (side yard and front yard), utility room and an attached garage.

LPA Montoya toured and inside and outside grounds of the facility with Staff Mejia. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.2 degree Fahrenheit. A comfortable temperature was maintained in the facility.



LPA observed the facility was found to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 6/15/2022. A working telephone remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUMMERWIND MANOR
FACILITY NUMBER: 197608011
VISIT DATE: 09/13/2022
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed deficiencies and issued citations. $500.00 Civil penalty assessed.

LPA was unable to provide a hard copy of the report due to technical difficulties.

An exit interview was conducted with Staff Jemimah Mejia. LPA will email an electronic copy of the report with appeal rights and civil penalty to Staff Jemimah Mejia for signatures.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/14/2022 05:34 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SUMMERWIND MANOR
FACILITY NUMBER: 197608011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, licensee did not comply with the section cited above. LPA Montoya observed the kitchen cabinets are greasy and the garage is cluttered. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
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Administrator shall degrease the cabinets and organize the garage. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by 9/27/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/14/2022 05:34 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SUMMERWIND MANOR
FACILITY NUMBER: 197608011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
(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 Marshall. Prior to accepting or rataining 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 Marshall. (1) Bedridden persons.

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. Resident #1 who is bedridden sleeps in bedroom B (#2) that is not approved for bedridden. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Administrator Sol agreed to move R1 to bedroom (#A) that has a fire clearance for bedridden. Administrator shall ask the resident and her family prior to making a move. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by 9/15/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4