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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603302
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:40:32 PM


Document Has Been Signed on 01/27/2023 12:40 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:SUMMIT VIEW HOME CAREFACILITY NUMBER:
198603302
ADMINISTRATOR:CASTRO, SILVIAFACILITY TYPE:
740
ADDRESS:107 CLEARVIEW CREST DRTELEPHONE:
(909) 396-7839
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 6DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Silvia Castro AdministratorTIME COMPLETED:
12:46 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit for the purpose of conducting the required annual inspection focused on infection control. On today's visit LPA was greeted by DSP Theresa Kuwashima and Administrator Silvia Castro arrived a short time later and assisted with the visit. Administrator certificate expires 10/14/2024 Last fire drill was on 11/20/2022

LPA discussed infection control practices with Ms. Castro, toured the facility inside and out, reviewed food supply. Temperature measured 117- 119.3 which is within regulatory range.

Structure/Physical Plant:
The facility is part of a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, electric oven, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) resident rooms, (1) bathroom; bathroom with shower, toilet and washbasin, Laundry closet with washer and dryer and storage for toxins. (1) Staff room with personal bathroom that are both inaccessible to residents. A front yard and a backyard with shaded/furnished area for resident use. A connected garage inaccessible to residents for storage. The residence is equipped with central air and heating.

The following were observed/inspected:
· The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
· COVID-19 signage was placed in several areas of the facility. Visitors are screened in the main entrance and a log is kept.
· LPA was screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility, in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.

(CONTINUED ON 809C)

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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 01/27/2023 12:40 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: SUMMIT VIEW HOME CARE
FACILITY NUMBER: 198603302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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. LPA observed two staff not wearing mask inside the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2023
Plan of Correction
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Administrator will provide training on infection control and send signed roster of all staff by POC date.
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

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. Room one which is shared did not have the required chairs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2023
Plan of Correction
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Administrator placed 2 chairs in room 1 during visit. ****NO FURTHER ACTION IS REQUIRED****
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 01/27/2023 12:40 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: SUMMIT VIEW HOME CARE
FACILITY NUMBER: 198603302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(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 . LPA and administrator observed a container of bleach in the outside patio area and assessable to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2023
Plan of Correction
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Bleach was removed and made in assessable to residents during visit, no further action is required. ***NO FURTHER ACTION IS REQUIRED*****
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based observation and record review, the licensee did not comply with the section cited above. R1 had one PRN (diclofenac) with no label. R3 had 3 over the counter medications without labels. (Liquid Meletonin, stool softener, and Laxatine). R4 had 3 overt the counter/PRN medications (Stool softener, Acidphilus and vitamin C) without labels which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2023
Plan of Correction
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Administrator will place labels on over the counter medications and PRN. Administrator will conduct training for all staff on the proper way to store, administrator and label over the counter medications and PRN and send proof to LPA by POC 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: SUMMIT VIEW HOME CARE
FACILITY NUMBER: 198603302
VISIT DATE: 01/27/2023
NARRATIVE
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· PPEs were observed. Facility maintains at least 30-day supply of PPE at facility.
· Staff responsible for direct care and supervision were not observed wearing masks initially.
· 4 resident medication records were reviewed.
· Residents were not observed to be wearing masks but adhering to public health social distance guidelines.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Please see 809D for details. Exit interview held and a copy of the report and appeal rights was provided to Ms. Castro.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4