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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201889
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:48:23 PM


Document Has Been Signed on 10/10/2023 03:48 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:SUMMERLAND MANORFACILITY NUMBER:
198201889
ADMINISTRATOR:VIRGINIA R. FELICIANOFACILITY TYPE:
740
ADDRESS:17708 CRENSHAW BLVETELEPHONE:
(310) 329-0799
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Bienvenido M. CadungogTIME COMPLETED:
04:01 PM
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On 10/10/2023 Licensing Program Analyst (LPA), David España conducted an unannounced visit to Summerland Manor. The purpose of today’s visit was to conduct a 1-year annual Inspection. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA verified that the facility has an approved mitigation plan report. LPA met with caregivers (S2) Estelita Mariano Fulgueras, (S3) Wenceslao Fulgueras, and Administrator/Manage, Bienvenido M. Cadungog (S1). Four (4) clients and three (3) staff were present during this inspection. This facility is licensed to serve six (6) elderly residents ages 60+, fire cleared for five (5) non-ambulatory and one (1) bedridden for room #4, facility is licensed to serve one (1) hospice resident and is 87705, with an approved hospice waiver for three (3) residents as of 11/21/2012.

The Annual Licensing Fees are current. The home is in a residential neighborhood with four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, one (1) living room, one (1) dining room, one (1) kitchen and 1 attached garage. LPA toured with S1 inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. At 8:15 AM LPA observed that both exterior backyard exits were locked, the north exits was locked from the outside using a wooden latch from the outside and the south exit was locked by a nail inserted to the gate latch. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 8:45 AM LPA observed full bed rails on 4 out of 4 residents (R1, R2, R3 and R4) beds. Resident bathrooms were checked.



Toilets and water faucets worked properly, grab bars were secured, showers were free of mold/mildew and non-skid mats were in place, hot water temperature properly measured at 116 degrees Fahrenheit. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions.There are no security bars or weapons on the premises.LPA toured the kitchen area and observed a two-day (2) supply of perishable and a seven-day (7) supply of non-perishable food. Knives and toxics were kept in locked storage cabinets. See LIC 809-C on the next page
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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 10/10/2023 03:48 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SUMMERLAND MANOR
FACILITY NUMBER: 198201889

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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. LPA and Administrator/Manage, Bienvenido M. Cadungog (S1) did not observe the following: S1, S2, S3, and S4 Verification of first aid training current as of 10/10/2023 per California Code of Regulations, Title 22, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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The administrator will create a plan to ensure future compliance to Title 22 Regulation 1569.618(c)(3) Staff. Proof of correction will be submitted to the department via email at David.espana@dss.ca.gov.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

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. LPA and Administrator/Manage, Bienvenido M. Cadungog (S1) did not observe the following: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: Date he/she assumed his/her position, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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The administrator will create a plan to ensure future compliance to Title 22 Regulation 87412(d) Administrator Certification Requirements. Proof of correction will be submitted to the department via email at David.espana@dss.ca.gov.
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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUMMERLAND MANOR
FACILITY NUMBER: 198201889
VISIT DATE: 10/10/2023
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First Aid kit was available. One fire extinguisher last serviced 11/22/2022 was observed near the rear exit in the kitchen area. LPA tested one carbon monoxide detector and one smoke detector located in the hallway area. Both devices were functional. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detectors. LPA also observed 1 out of 4 residents (R4) being secured to their wheelchair by caregiver S2 using a “safety band” on R2 Licensee verified that “safety band” has been approved by doctor for the safety and does not tie down resident it permits quick release by the residents.

At 9:40 AM LPA did not observe an updated Administrators Certificate, licensee stated that they are in the process of obtaining certificate. 4 staff records were reviewed, 4 out of 4 staff records did not have current first aid certificates. 4 resident records were reviewed and 4 out of 4 residents (R1, R2, R3 and R4) did have signed Admission Agreements, 4 out of 4 residents had updated Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

Deficiencies are being cited based on LPA observations, interviews conducted and record reviews in accordance with the California Code of Regulations (CCR), Title 22.

Two (2) Type B Deficiencies were cited:


Staffing - Type B: 1569.618(c)(3) -
Personnel Records/Staff Training - Type B: 87412(d)
Two (2) Technical Violation were issued:
Personnel Records/Staff Training - Technical Violation: 1569.625(b)(2)
Personnel Records/Staff Training - Technical Violation: 87411(c)(1)
Two (2) Technical Assistance were issued:
Personnel Records/Staff Training - Technical Assistance: 1569.626(a)(2)
Resident Rights/Information - Technical Assistance: 87468(c)(2)(A)

An exit interview was conducted, and a hard copy was provided with appeal rights to Administrator/Manage, Bienvenido M. Cadungog (S1).

See LIC 809-D on the next page

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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