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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608313
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:32:44 PM


Document Has Been Signed on 10/13/2023 03:32 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:INDIAN SUMMER PLACEFACILITY NUMBER:
197608313
ADMINISTRATOR:SAMANTHA ALEXFACILITY TYPE:
740
ADDRESS:1146 INDIAN SUMMER AVENUETELEPHONE:
(626) 333-4027
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY:6CENSUS: 4DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Samantha Alex - AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Samantha Alex (Administrator) and Henry Scott (staff) who assisted with the visit, the purpose for the visit was explained.

FACILITY LICENSED TO SERVE ELDERLY RESIDENTS AGE 60 AND ABOVE. FIRE CLEARANCE APPROVED FOR 6 AMBULATORY RESIDENTS.

During visit LPA toured the facility, reviewed client and staff records, reviewed client medications and facility files. There were 2 type A deficiencies observed during todays visit, one being hot water temperature and the other being disinfectants and cleaning supplies being accessible to clients in care. Details of these citations will be documented on the 809D page.

Due to time constraints, LPA will continue this inspection at a later date.
LPA will return to continue the required 1-year annual inspection.

Exit Report held and a copy of this report and appeal rights were provided to Administrator Samantha Alex.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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 10/13/2023 03:32 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: INDIAN SUMMER PLACE
FACILITY NUMBER: 197608313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)

(e)Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA tested water temperature in both client restrooms, one restroom measured at 128.6 and the other at 129.5, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Administrator to create a log for the next 5 days, where water temperature is measured morning, afternoon, and evening. These readings are to be documented with time, date and reading. Water temperature to be within the required range of 105-120 degrees F.Log to start on 10/14/2023 and end on 10/18/2023. Log to be submitted via E-mail to LPA by 10/19/2023. Administrator to test water temperature regularly to ensure water temperature remains within range.
*Note staff lowered water heater temperature during visit*
Type A
Section Cited
CCR
87309(a)
(a)Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed cleaning solutions in an unlocked cabinet under client bathroom sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Staff removed cleaning solutions from unlocked cabinet and stored them in a locked and secured location during vistit.
**Administrator to conduct a in house training to ensure all staff are knowledgable in where and how to properly store disinfectants, cleaning solutions, and poisons. Training log with training information to be submitted to LPA by 10/19/2023. Information must have date of training, who attended (with signatures of participant), who conducted the training and what was reviewed during training.**
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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