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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570301295
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:42:47 PM

Document Has Been Signed on 05/24/2022 04:42 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SUMMER HOUSE INC.FACILITY NUMBER:
570301295
ADMINISTRATOR:YOUNG, SAMANTHAFACILITY TYPE:
735
ADDRESS:206 5TH STTELEPHONE:
(530) 662-8493
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 12CENSUS: 11DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Sam Young, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Summer House for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO). LPA was met by Administrator, Sam Young, and was granted access into the facility.

A facility tour was conducted on May 24, 2022 at approximately 2:10 PM. LPA reviewed the Special Incident Report (SIR) dated on April 11, 2022, reporting a medication error. The error occurred on 04/10/22 while S1 was dispensing medication. R1 was given the wrong prescribed medication during medication administration. Responsible party and prescribing doctor were notified of medication error. R1 was observed for possible side effects. No side effects were reported. LPA interviewed administrator, made observations and inspected the medication room and reviewed medication administration protocols. Various documents were reviewed including Centralized Stored Medication Record (CSMR), Medication log, staff training hours.


Deficiencies are cited from the California Code of Regulations (CCRs), Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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 05/24/2022 04:42 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 05/24/2022 at 03:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SUMMER HOUSE INC.
FACILITY NUMBER: 570301295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2022
Section Cited
CCR
80075(b)

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-Health Related Services-Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:



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Administrator/Licensee will ensure that all clients receive assistance with medication as prescribed by the physician. Facility will conduct training and re-training regarding medication administration and provide proof of successful completion by staff.
POC cleared during visit.
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Based on the 4/11/22 Incident report and interviews conducted, a medication error occurred when staff gave R1 another client's medication which poses an immediate risk to the health and safety of clients in care.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
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