347001484-5-4-2023-27-AS-AMAZ-CRHVF2-20230504162313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001484
Report Date: 05/04/2023
Date Signed: 05/04/2023 04:23:21 PM

Document Has Been Signed on 05/04/2023 04:23 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SUMMER'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	347001484
ADMINISTRATOR:	PAUL LOMENDEHE		FACILITY TYPE:	740
ADDRESS:	130 MANITOU STREET		TELEPHONE:	(916) 567-0759
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95838
CAPACITY:	5	CENSUS: 5	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Wane Tambunan and Juli Susanti Gultom		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee made an unannounced visit to this facility to conduct an annual required inspection on 05/04/2023 at 2:00 PM. LPAs met with Wane Tambunan and Juli Susanti Gultom and explained the purpose of today's visit. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for five non-ambulatory residents. There are currently five residents who reside at this facility. The facility is approved for a hospice waiver for one resident.

The LPAs toured the facility with Juli Susanti Gultom on 05/04/2023 at 2:45 PM.

The facility has and adequate food supply, and the kitchen was sanitary. The facility water temperature measured at 110 degrees. In addition, all toxins were made inaccessible to clients in care. The resident bed rooms and bathrooms were furnished, and the facility has a public telephone. The facility has an area for visitors and has covid-19 postings throughout the facility. The facility has the required posting throughout the facility. The facility hall light was not in good repair.

LPAs inspected smoke detectors, carbon detectors, and fire extinguisher, which they were all in good repair. the facility has a first aid kit. The facility resident and staff files were current. LPAs conducted a medication file review. LPAs reviewed two medication files. The two medication files did not have a current Centrally Stored Medication and Destruction Records.

As a result of this visit, the following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeals right given were given to the facility at the end of visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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 05/04/2023 04:23 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUMMER'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 347001484
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)

87465 (h)(6) Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored…The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and file review resident 1 did not have a current Centrally Stored Medication and Destruction Record. The last Centrally Stored Medication and Destruction Record was for 2022. R2 Centrally Stored Medication and Destruction Record. was not current. Last Centrally Stored Medication and Destruction Record. record was in 2022. This posed a potential health and safety risk to R1.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Facility staff agrees to conduct Incidental and Medical training for all staff due by POC date 05/18/2023. Staff agrees to email training document to LPA Martinez by POC date 05/18/2023 by 5 PM.

Type B

Section Cited

CCR

87303(a)

87303 (a) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and inspection the resident hallway light was out. LPAs inspected light switch to turn on hallway light, however, the hallway light did not turn on. This posed a potential health and safety risk to residents in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Facility staff agrees to repair hall way light by POC date 05/18/2023. Facility staff agrees to email LPA Martinez a picture of working Hall light by poc Date 05/18/23 by 5 PM

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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