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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608011
Report Date: 10/11/2023
Date Signed: 10/11/2023 12:12:39 PM


Document Has Been Signed on 10/11/2023 12:12 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
EL SEGUNDO, 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:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Jemimah Mejia/AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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On 10/11/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Jemimah Mejia /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above of which (5) may be non-ambulatory and (1) bedridden. Facility has an approved hospice waiver for (4) residents.

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 Iniguez toured the physical plant with staff. There were no obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational (See D page for citation). LPA inspected rooms: #1, #2, and #3, smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 108.6°F, Bathroom #1:106.9°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUMMERWIND MANOR
FACILITY NUMBER: 197608011
VISIT DATE: 10/11/2023
NARRATIVE
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents (See D page for citation). The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files and (3) Medication Administration Records (MAR) were maintained in order. First AID kit was checked. Last facility disaster drill was on:6/2/2023

A copy of the liability insurance was provided to LPA during visit.

LPA observed the facility's infection control practices.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Jemimah Mejia /Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/11/2023 12:12 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SUMMERWIND MANOR
FACILITY NUMBER: 197608011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in not locking the kitchen cabinet where cleaning supplies were found which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
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Administrator locked kitchen cabinet while LPA was at the facility. As part of POC, administrator will re-train all staff regarding keeping lock cleaning supplies at all times. A proof of the training will be submitted to LPA before POC due date via email.
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) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/11/2023 12:12 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SUMMERWIND MANOR
FACILITY NUMBER: 197608011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023

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 the licensee did not comply with the section cited above in having the kitchen cabinet broken and mildew residue in one of the bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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Administrator must ensure the kitchen cabinet will be repaired. The mildew residue in tha bahtroom has to be treated and the bottom molding has to be replaced beofre POC due date, a proof of correction will be submitted to LPA before POC due date via email.
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) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4