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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608232
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:43:23 PM

Document Has Been Signed on 12/16/2021 04:43 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:SUMMER HOUSE AT LADERA HEIGHTSFACILITY NUMBER:
197608232
ADMINISTRATOR:SHERRYL RAFOLSFACILITY TYPE:
740
ADDRESS:6108 DAMASK AVENUETELEPHONE:
(323) 792-4105
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 4CENSUS: 4DATE:
12/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Sherryl Rafols and Mark LooTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel made an unannounced visit to the facility and was greeted by caregiver Crisostomo Gaytos and spoke to Administrators Sherryl Rafols and Mark Loo via telephone. The purpose of this visit is to deliver a generated Case Management – Deficiencies, evaluation report in conjunction with Complaint Control #11-AS-20191113101336 due to the following observations:

This investigation revealed that Resident #1 was restrained to the bedrails utilizing pieces of cloth sheets and shirts. The cloth restraints were placed around the resident’s wrists – while the resident was wearing gloves. Staff #1 admitted the purpose of the restraints were to prevent Resident #1 from removing the Foley catheter and scratching its wounds; as the resident would get agitated. Staff #1 expressed the necessity to occasionally restrain Resident #1 in different positions in order to prevent the resident from placing pressure on its wounds. On several occasions, ComCare Home Health Nurse observed Resident #1 tied to the bed rails in this same manner and would instruct Staff #1 to immediately remove the restraints. It seemed to be a reoccurring event requiring the HHA Nurse to repeatedly order Staff #1 to remove these restraints from Resident #1.

Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation PERSONAL RIGHTS: Resident was restrained by the hands to the bedrails is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency was observed and a citation issued (ref. LIC 9099D).

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrator (FULL NAME).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
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 12/16/2021 04:43 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 12/16/2021 at 10:06 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2021
Section Cited
CCR
87468.1(a)(3)

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87468.1(a)(3) Personal Rights of Residents in All Facilities: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature; such as, withholding residents money or interfering with daily-living functions; such as, eating, sleeping, or elimination.
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The administrator shall read Title 22, Section 87468.1(a)(3) “Personal Rights of Residents in All Facilities” and send a written statement to CCLD by the POC date that Administrator will ensure that a resident in the facility will be free from punishment and abuse or other actions of a punitive nature.
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This requirement is not met as evidenced by: Staff #1 admitted the purpose of the restraints and expressed the necessity to occasionally restrain Resident #1 in different positions. Which poses a potential Health and safety risk to residents in care.
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 The plan is due to CCLD/El Segundo ASC Office by POC date of 12/24/2021.

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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:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021


LIC809 (FAS) - (06/04)
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