197608232-11-9-2023-11-AS-MVAO-D3QQ8F-20240326115636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608232
Report Date: 11/07/2023
Date Signed: 11/09/2023 03:10:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20231102124719

FACILITY NAME:	SUMMER HOUSE AT LADERA HEIGHTS		FACILITY NUMBER:	197608232
ADMINISTRATOR:	SHERRYL RAFOLS		FACILITY TYPE:	740
ADDRESS:	6108 DAMASK AVENUE		TELEPHONE:	(323) 792-4105
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY:	4	CENSUS: 4	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	08:36 AM
MET WITH:	Chris Gaytos and Mayet Neri		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not keeping medications in a safe and locked location.
Staff are not keeping dangerous items in a safe and locked location.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, November 07, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with staff Chris Gaytos and Mayet Neri. LPA spoke to Licensee Mark Loo via telephone. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: Interviews conducted with staff 1-3 (S1-S3), residents 1-3 (R1-R3), and witness 1 (W1) LPA Bunker was unable to interview resident 4 (R4), R4 was sleeping and is hard of hearing. LPA Bunker asked questions relevant to the nature of the complaint. Staff Mayet and LPA Bunker toured the entire facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visits. LPA Bunker reviewed residents' medication records in the facility-locked cabinet in the hallway. LPA observed resident knives in a locked cabinet in the kitchen inaccessible to residents. LPA Bunker requested copies of supporting documents. See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231102124719

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS	FACILITY NUMBER: 197608232
	VISIT DATE: 11/07/2023

NARRATIVE

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See continued LIC9099-C page 2

Allegation #1: Staff are not keeping medications in a safe and locked location.
LPA Bunker conducted interviews with staff 1-3 (S1-S3), residents 1-3 (R1-R3), and witness 1 (W1) regarding the allegation that, on October 31, 2023, resident medications were stored in a locked cabinet in the hallway, and medication is consistently secured. S1-S3, R1-R3, and W1 unanimously affirmed that staff diligently safeguard residents' medications at all times, maintaining them in a secure, locked
place. In summary, all parties interviewed denied the allegation.

Allegation #2: Staff are not keeping dangerous items in a safe and locked location.
LPA Bunker interviewed staff 1-3 (S1-S3), residents 1-3 (R1-R3), and witness 1 (W1) concerning the alleged allegation of dangerous items not being stored in a secure, locked location. According to their statements, knives in the facility are stored in a locked cabinet in the kitchen, ensuring that they are inaccessible to residents in care. S1-S3, R1-R3, and W1 consistently denied the allegation.

The investigation consisted of the following: Interviews with staff 1-3 (S1-S3), residents 1-3 (R1-R3), and W1, who all attested that medications are consistently stored in a safe, locked location. Staff confirmed that they unlocked the medication cabinet to dispense medication to residents, promptly locking it afterward. Medication is never left unattended in the kitchen at eye level. S1-S3 emphasized that medications are appropriately labeled and maintained in compliance with regulations. Medications are securely locked and inaccessible to residents. The same rigorous safety measures apply to dangerous items, which are kept in a locked kitchen cabinet, with kitchen knives only taken out for cooking and food preparation. S1-S3, R1-R3, and W1 affirmed that residents do not have access to the kitchen area, ensuring their safety. Staff takes great care to meet residents' needs, and S1-S3 emphasized their training and competence in delivering the necessary services. They are committed to preventing residents from harm, injury, and danger. R1-R3 expressed their satisfaction with the staff's kindness and quality of care, stating they are content living at the facility. S1-S3, R1-R3, and W1 collectively denied the allegations.

See continued LIC9099-C page 3

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231102124719

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUMMER HOUSE AT LADERA HEIGHTS	FACILITY NUMBER: 197608232
	VISIT DATE: 11/07/2023

NARRATIVE

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See continued LIC9099-C page 3

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099 and LIC9099-Cs provided to the facility staff.

There were no deficiencies cited. An exit interview was conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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