197608313-10-22-2021-28-AS-CYEE-C9D5XN-20211203192102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608313
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:56:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2020 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200526142231

FACILITY NAME:	INDIAN SUMMER PLACE		FACILITY NUMBER:	197608313
ADMINISTRATOR:	SAMIEPER DUQUE		FACILITY TYPE:	740
ADDRESS:	1146 INDIAN SUMMER AVENUE		TELEPHONE:	(626) 333-4027
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY:	6	CENSUS: 4	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Samantha Alex, administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of adequate supervision resulted in resident wandering from the facility on multiple occasions

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegation listed above. LPA Spencer met with administrator Samantha Alex (Samieper Duque) and explained the purpose of today's visit.

The investigation consisted of the following: The initial complaint investigation was conducted by LPA Juan Pablo Miramontes on 6/2/20 telephonically. A subsequent visit was conducted by LPA Spencer on 9/29/21 who interviewed the administrator, staff #1 (S1), and residents #1-2 (R1-R2). LPA took a tour of the physical plant and obtained documents for R6 including: admissions agreement, house rules, physician's report, medications list, hospital discharge papers, and caregiver's notes. During the course of the investigation, LPA interviewed R6's family member (F1) and attempted to reach R6's physician who could not be reached. On today's visit, R3-R4 were interviewed. R5 was not at the facility during the visit and R6 is a previous resident and could not be interviewed because R6 passed away.
***See LIC9099C for continuation of this narrative***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20200526142231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INDIAN SUMMER PLACE	FACILITY NUMBER: 197608313
	VISIT DATE: 10/22/2021

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
26
27
28
29
30
31
32

The investigation revealed the following:

Lack of adequate supervision resulted in resident wandering from the facility on multiple occasions

All staff and residents interviewed stated that there is adequate supervision at the facility at all times. Staff denied the allegation and indicated that the R6 was independent and physician's report allowed R6 to leave the facility unassisted. R1-R2 stated that they knew of one resident that would leave the facility and get picked up by police on several occasions due to appearing disoriented, but that all residents were allowed to leave when they wanted to. R3-R4 stated that they did not know of any residents that wandered away from the facility and that residents are allowed to come and go independently. F1 stated that R6 often wandered away from the facility and should have been placed in a locked facility because of R6's mental capabilities. A review of the house rules states that residents can leave the facility, but must sign in/out, and observe curfew at 9 p.m. A review of caregiver's notes reveals that R6 did leave the facility on multiple occasions without observing house rules. A review of R6's physician's report reveals that R6 is ambulatory and is able leave the facility unassisted.

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 Unsubstantiated.

An exit interview was conducted and a copy of this report was provided to the administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2