197608011-9-13-2024-11-AS-SLEO-D93VHV-20240913162747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608011
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:27:59 PM

Document Has Been Signed on 09/13/2024 04:27 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUMMERWIND MANOR		FACILITY NUMBER:	197608011
ADMINISTRATOR:	JOSEPH SOL		FACILITY TYPE:	740
ADDRESS:	3117 W. CARSON STREET		TELEPHONE:	(310) 328-1671
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Administrator - Joseph Sol		TIME COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/13/2024 at around 8:20 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Joseph Sol. LPA explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection. This facility is licensed to serve 6 adults ages 60 and above, of which 5 maybe non-ambulatory, 1 maybe be bedridden, and 4 maybe on hospice. A total of 6 residents are currently residing in this facility. The facility is a one-story house located on a main street. The home consists of 4 resident bedrooms, 2 bathrooms, 1 family room, 1 dining room, 1 kitchen, 1 attached garage, 1 laundry room and 1 backyard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. There are no security bars or weapons on the premises.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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 09/13/2024 04:27 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMERWIND MANOR	FACILITY NUMBER: 197608011
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having: a cracked mirror sliding closet door; loose cables in a bedroom, family room, and outside walkway; medicine cabinet mirror doors not closing properly; bedroom closet missing a doorknob, which poses a potential safety and personal rights risks to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	Licensee agrees to fix the cracked mirror sliding closet door; loose cables in a bedroom, living room, and outside walkway; medicine cabinet mirror doors not closing properly; and replace the doorknob on the bedroom closet. Licensee will email proof of corrections to Socorro.Leandro@dss.ca.gov.

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a scissor in an unlocked cabinet, which poses a potential safety risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	The Licensee agreed to retrain staff on how/where to store items which could pose a danger if readily available to residents in care. Licensee will email staff trainings to Socorro.Leandro@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2024 04:27 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMERWIND MANOR	FACILITY NUMBER: 197608011
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.319(a)

Regulations

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above in not having a videoconferencing device dedicated for resident use, which poses a personal rights risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	The Licensee agrees to provide facility with a videoconferencing device to persons in care. Licensee will email a receipt, picture, and plan of how they plan to provide the facility with a videoconferencing device dedicated for resident use. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, and interview conducted, the licensee did not comply with the section cited above in not having a complete and current record of the Medication Administrator Record (MAR) for Resident 1 (LPA observed several mistakes on R1’s MAR), which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	The licensee agrees to retrain staff on how to provide medications to residents in care and how to document Medication Administration Record (MAR). Licensee will email staff trainings to Socorro.Leandro@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2024 04:27 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMERWIND MANOR	FACILITY NUMBER: 197608011
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 residents not having their TB test results, which poses a potential health to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	Licensee agrees to email Resident 2's TB results to Socorro.Leandro@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMERWIND MANOR	FACILITY NUMBER: 197608011
	VISIT DATE: 09/13/2024

NARRATIVE

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LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.

LPA observed that medications were safe, locked, and inaccessible. Documents are posted as mandated. Last drill was conducted on 9/1/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There are two fire extinguishers on the premises and they were last serviced on 08/7/2023.

4 out of 4 residents’ bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.

5 resident records were reviewed and, 1 out of 5 resident records were missing tuberculosis (TB) test results.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMERWIND MANOR	FACILITY NUMBER: 197608011
	VISIT DATE: 09/13/2024

NARRATIVE

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Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22. Violations regarding facility being in disrepair, scissors being available to residents in care, no videoconferencing device dedicated for client use, mistakes on the Medication Administration Record (MAR) for residents in care, and not having a TB test result for a resident in care.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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