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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608232
Report Date: 07/21/2023
Date Signed: 08/10/2023 08:42:23 AM

Document Has Been Signed on 08/10/2023 08:42 AM - 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: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:
07/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Chris GaytosTIME COMPLETED:
02:00 PM
NARRATIVE
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On 7/21/2023 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on the Annual processed on prior visits. LPA was greeted by Chris Gaytos, Staff. LPA spoke with Chris and explained the purpose of the visit was to gather information to complete Annuals processed on 3/28/23 and 5/19/23. The census for today is 4.


The following documents were requested and received during the visit:

· Copy of Liability Insurance
· Updated LIC 500

The following deficiencies were observed during the visit:
-At 09:55 am LPA took hot water temperate in facility kitchen and noted that it was 120.8 F.
-At 09:57 am LPA observed that cabinet in kitchen which held medication was not locked.
-At 10:03 am LPA observed that bed in first bedroom did not have proper layers.
-At 10:05 am LPA observed that R1 had postural supports with no prescription
-At 10:06 am LPA observed a bottle of Lysol under bathroom sink, cabinet did not have a lock
-At 10:06 am LPA observed Lysol and Clorox wipes located on rack above toilet in bathroom accessible to residents.

An exit interview was conducted and a copy of this report and appeal rights were provided to caregiver Chris Gaytos.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 07/21/2023 02:00 PM - It Cannot Be Edited


Created By: Felisa Shirley On 07/21/2023 at 11:39 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: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/22/2023
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation
Faucets used by the staff in the kitchen shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperture of hot water used to attain a temperature of not less than 105 degrees F and not more than 120 degree F.

This requirement is not met as evidenced by:
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Licensee will monitor water over next 24 hours and submit proof that water is between 105 F and 120 F bia fax to CCLD.
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Based on observation, the licensee did not comply with the section cited above. LPA found water temperature in kitchen to be 120.8, which poses an immediate health, safety or personal rights risk to persons in care.
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Request Denied
Type A
07/22/2023
Section Cited
CCR87309(a)(1)

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which coluld pose a danger if readily available to clients shall be stored where inaccessible to clients. (1)Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement was not met as evidenced by:
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Licensee will put a lock on cabinet door located under the bathroom sink and put all toxins in locked cabinet.
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Based on observation the licensee did not comply with the section cited above by having toxins accessible to clients which poses an immediate health and safety risk to persons in care.
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/21/2023 02:00 PM - It Cannot Be Edited


Created By: Felisa Shirley On 07/21/2023 at 12:18 PM
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: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/22/2023
Section Cited
CCR
87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place.

This requirement is not met as evidenced by:
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Licensee shall lock at medications away and make inaccessible to residents.
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Based on observation, the licensee did not ensure safety by not locking up medications making them inaccessible to residents which could pose as an immediate health and safety risk to persons in care.
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Request Denied
Type B
08/04/2023
Section Cited
CCR87307(3)(c)

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(3)Equipment and supplies necessary for personal care and maintenance of a adequate hygience practice shall be readily available to each resident. (c)clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads

This requirement is not met as evidenced by:
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Licensee shall provide proper linens for residents beds.
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Based on observation, the licensee did not ensure that residents were provided proper linens for bedding, which could pose as an immediate health and safety risk to persons in care.
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/21/2023 02:00 PM - It Cannot Be Edited


Created By: Felisa Shirley On 07/21/2023 at 01:03 PM
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: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/04/2023
Section Cited
HSC
87608(a)(3)

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(a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
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Licensee shall remove hospice rails and provide a copy once removed to CCLD via fax.
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Based on observation and file review, the licensee did not ensure safety by having postural supports on residents bed, which could pose as an immediate health and safety risk to persons in care
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
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