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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608313
Report Date: 10/11/2021
Date Signed: 10/11/2021 03:10:46 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200721115641
FACILITY NAME:INDIAN SUMMER PLACEFACILITY NUMBER:
197608313
ADMINISTRATOR:SAMIEPER DUQUEFACILITY TYPE:
740
ADDRESS:1146 INDIAN SUMMER AVENUETELEPHONE:
(626) 333-4027
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY:6CENSUS: 5DATE:
10/11/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:S-1TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Lack of supervision resulting in resident to resident abuse
Staff do not meet the minimum qualifications required by licensing
Resident wandered away from the facility while in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with S-1 and discussed the pupose of today's visit.

On 07/30/2020, LPA Miramontes initiated this investigation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted this investigation telephonically with Samantha Alex (Facility Administrator). LPA obtained relevant documentation for this complaint investigation.

During this investigation, LPA Irra interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown.

***Refer to LIC 9099C for the continuation of this report***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 28-AS-20200721115641
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INDIAN SUMMER PLACE
FACILITY NUMBER: 197608313
VISIT DATE: 10/11/2021
NARRATIVE
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Allegation: Lack of supervision resulting in resident to resident abuse. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed R-7 and R-8 would come in and out of this facility independently. Interviewed staff indicated Residents, at times, will get into verbal altercations and does not lead to physical contact. Per interviews, Staff are able to redirect Residents when this occurs. Interviewed staff indicated that they have not witnessed nor heard anyone stating that residents are being abused. Interviewed staff indicated that staff provide care and supervision to residents. Interviewed residents indicated there is staff providing care and supervision for residents. Interviewed residents indicated they have not witnessed any residents to resident abuse. Staff and Resident interviews do not corroborate this allegation.

Allegation: Staff do not meet the minimum qualifications required by licensing
During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed that staff are trained in resident rights, reporting requirements, supervision, resident abuse. Interviewed Residents were unable to provide an answer to this allegation as they do not know the minimum qualifications by licensing. Interviews do not corroborate this allegation.

Allegation: Resident wandered away from the facility while in care
During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Per staff interviews, R-7 and R-8 did not wonder out of this facility and indicated that R-7 and R-8 would go out in the community independently and return to this facility. Interviewed staff indicated residents do not wonder away from this facility. Interviewed residents indicated they have not witnessed nor heard of any residents wandering away from this facility. Interviewed residents indicated that residents whom leave the facility are independent and return to the facility. Per Staff interviews and record reviews, both R-7 and R-8, were independent and able to be out in the community unsupervised. Interviews and file reviews do not corroborate this allegation.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20200721115641
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INDIAN SUMMER PLACE
FACILITY NUMBER: 197608313
VISIT DATE: 10/11/2021
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are unsubstantiated.

Exit interview conducted, copy of this report and appeal rights were provided to S-1.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200721115641

FACILITY NAME:INDIAN SUMMER PLACEFACILITY NUMBER:
197608313
ADMINISTRATOR:SAMIEPER DUQUEFACILITY TYPE:
740
ADDRESS:1146 INDIAN SUMMER AVENUETELEPHONE:
(626) 333-4027
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY:6CENSUS: 5DATE:
10/11/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:S-1TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Allegation: Staff failed to properly report incidents regarding residents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with S-1 and discussed the pupose of today's visit.

On 07/30/2020, LPA Miramontes initiated this investigation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted this investigation telephonically with Samantha Alex (Facility Administrator). LPA obtained relevant documentation for this complaint investigation.

During this investigation, LPA Irra interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown.

***Refer to LIC 9099C for the continuation of this report***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20200721115641
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INDIAN SUMMER PLACE
FACILITY NUMBER: 197608313
VISIT DATE: 10/11/2021
NARRATIVE
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Allegation: Staff failed to properly report incidents regarding residents.
During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed that staff are trained in reporting special incidents. Interviewed staff indicated that it is responsibility to report special incidents to the Facility Administrator and in turn, the Facility Administrator reports the incidents to the appropriate entities. LPA was unable to obtain any special incidents for R-7 or R-8. Per staff interviews, R-8 indicated R-8 hit R-7 and staff interviewed all Residents. Per Staff interviews, no residents witnessed R-8 hitting R-7. Per file review, staff only had a hand written note on R-7’s and R-8’s file and was not reported to Licensing but was reported Long Term Care Ombudsman (LTCO). Per staff interviews, staff were under the impression that LTCO cross reports to Licensing. Per Staff interviews and record reviews, both R-7 and R-8, were independent and able to be out in the community unsupervised. Interviewed Residents were unable to provide an answer to this allegation as they do not know the special incident report guidelines. Staff interviews and file review corroborates this allegation.

Based on observations, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights were provided to S-1.

NOTE: LPA was experiencing technical difficulties during today's visit.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20200721115641
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2021
Section Cited
CCR
87211(a)(1)(B)
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87211 Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but no limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events
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Administrator provided staff training on reporting requirements and provided proof of correction to LPA Irra during today's visit.
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specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
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Type B
10/12/2021
Section Cited
CCR
97211(a)(1)(B)
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This is a continuation of the 87211(above). This standard is not met as evidence by: LPA was unable to obtain any special incidents for R-7 or R-8. Per staff interviews, R-8 indicated R-8 hit R-7 and staff interviewed all Residents. Per Staff interviews, no residents witnessed R-8 hitting R-7. Per file review, staff only had a written note on R-7's and R-8's file and was
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not reported to Licensing but was reported Long Term Care Ombudsman (LTCO). Per staff interviews, staff were under the impression that LTCO cross reports to Licensing
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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: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6