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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608232
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:07:58 PM


Document Has Been Signed on 03/15/2024 03:07 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 5DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver Crisostono GaytosTIME COMPLETED:
12:08 PM
NARRATIVE
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On 03/15/24 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Caregiver Crisostono Gaytos as the purpose of the visit was explained. The facility is licensed to serve clients with dementia ages 60 and above. Facility is approved for four (4), non-ambulatory clients, one (1) bedridden in room #2 only, hospice waiver for two (2). Current facility census is 5, facility fees are current.

The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: three (3) resident's rooms, one (1) staff room, three (3) bathrooms of which one (1) is for staff and visitors only, living room area, dining area, kitchen with a laundry area. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of two(2) staff records, three (3) client records, and three (3) medication administration records, medications were centrally stored and properly locked. First aid kit was checked and fully stocked. The last fire was conducted on 03/05/20, four (4) fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational.

citations documented on 809D page.

Exit interview conducted with Caregiver Crisostono Gaytos, appeal rights explained and a copy of this report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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 03/15/2024 03:07 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above as administrator and caregiver have expired first aide documentation in their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator to provide proof of current/active first aide documentation of all staff to LPA by POC due date.
Type B
Section Cited
CCR
87705(j)
Care of persons with dementia

The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above as bedroom A which has a sliding exit door does not have an auditory device which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator to place auditory devices on all doors to ensure compliance with section above. Administrator to provide proof to LPA by POC due date.
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 HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 03/15/2024 03:07 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87217(b)
Safeguards for Resident Cash, Personal Property, and Valuables

Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.


Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Client #1 (LM) and Cliet #3(H.H.)
do not have a personal property and valuables form in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator to safeguard personal propertt ad valuables for resident #1 and # 3 and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87303(a)(1)
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.

Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.


Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as LPA observed facility walls to be dirty, paint is chipping off and walls have spider webs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator to hold inservice with staff regarding keeping the facility shall be clean, safe, sanitary and in good repair at all times. Administrator to provide proof of inservice to LPA by POC due date.
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 HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/15/2024 03:07 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87407(d)
Administrator Recertification Requirements
To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department’s Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as LPA did not observe an active administrator certificate posted at the facility nor in Administrator file. Expired certificate observed, experation date : 11/13/2021. Facility staff could not provide proof of active admin certificate at the time of visit
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator to provide proof of active admin certificate by POCdue date.
Type B
Section Cited
HSC
1569.605
Liability insurance; coverage requirements

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as facility staff could not provide proof of liability insurance at the time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator to provide proof to LPA of active/current liability insurance by POC due date.
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 HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4