INDIAN SUMMER PLACE

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 5 residents are being medication without the physician's orders which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/04/2025 Plan of Correction The licensee shall ensure all the medications have physician's orders. Licensee shall submit the staff in-service training on medication along with the plan to ensure medication is properly administered by POC due date 10/4/25.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited in that the facility could not provide proof of the liability insurance which poses a potential health, safety rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2025 Plan of Correction The licensee shall provide proof of the liability insurance showing $1,000,000 per occurrence and $3,000,000 in total aggregate

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was unable to provide LPA proof of liability insurance during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2024 Plan of Correction Facility to provide LPA proof of Liability insurance via email or FAX by POC due date.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(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 Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Administrator Samantha Alex has an expired certificate and has not submitted packet for renewal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2024 Plan of Correction Administrator to schedule required administrator trainings and submit packet for administrator certificate renewal by POC due date. LPA advised to request extension if needed to complete required trainings.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the centrally stored medication list with medication names and dosages was not udpated for (6) of (6) residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2024 Plan of Correction Facility to complete list of centrally stored medications and their dosages for each resident by POC due date. LPA advised that the LIC 622 can be used.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as (2) of (6) resident files were not available for LPA review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2024 Plan of Correction Faciltiy to gather required resident records for all residents in care and keep them in a centralized location in the facility by POC due date. Copies of resident #5 and resident #6 files can be sent via FAX to LPA as POC.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one client bathroom measured at 127.2 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Administrator to create a log for the next 5 days, where water temperature is measured morning, afternoon, and evening. These readings are to be documented with time, date and reading. Water temperature to be within the required range of 105-120 degrees F.Log to start on 10/25/2023 and end on 10/29/2023. Log to be submitted via E-mail to LPA by 10/30/2023. Administrator to test water temperature regularly to ensure water temperature remains within range. *Note Administrator lowered water heater temperature during visit*

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 Based on observation, the licensee did not comply with the section cited above as LPA observed knives to be stored in unlocked pantry and medication cabinet was unlocked within the unlocked kitchen, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Administrator to create a written plan as to where and how disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients will be stored for all staff to understand and be in compliance. This plan is to be Emailed to LPA by 11/7/23, and shall be dated and have signatures of all staff. *Administrator locked medicine cabinet and stored knives in 2nd drawer of locked cabinet during visit*

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as Administrator could not furnish proof of Infection Control Plan during time of visits, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Administrator to create and Infection Control Plan and submit plan to LPA by POC due date. This plan is to remain within facility file.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as during initial and subsequent visits residents beds were either missing the required mattress pad or sheets, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2023 Plan of Correction Administrator to place proper bedding on resident beds and submit proof of correction with photots that show all required bedding on each resident bed (not including 1 resident as it is thier preferance to not have sheets on their bed). Photos to be submitted to LPA via email by POC due date.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(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 Based on record review and conversation with Administrator, the licensee did not comply with the section cited above as Administrator currently does not have a valid Administrator Certificate or required trainings, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Administrator Samantha Alex to sign up for needed trainings to update Administrator Certificate. Proof of training (or enrollment) along with all other requirements found on CCL website for Administrator to be submitted via email to LPA by POC due date.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA toured facility on both Initial and subsequent visits and Complaint poster was not posted anywhere inside the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Administrator to obtain a copy of the required Residential Care Facility for the Elderly (RCFE) Complaint Poster that is 20 " x 26 " and post it in a main entryway of the facility and email photos of poster in entryway to LPA by POC due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e)Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA tested water temperature in both client restrooms, one restroom measured at 128.6 and the other at 129.5, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2023 Plan of Correction Administrator to create a log for the next 5 days, where water temperature is measured morning, afternoon, and evening. These readings are to be documented with time, date and reading. Water temperature to be within the required range of 105-120 degrees F.Log to start on 10/14/2023 and end on 10/18/2023. Log to be submitted via E-mail to LPA by 10/19/2023. Administrator to test water temperature regularly to ensure water temperature remains within range. *Note staff lowered water heater temperature during visit*

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 Based on observation, the licensee did not comply with the section cited above as LPA observed cleaning solutions in an unlocked cabinet under client bathroom sink, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2023 Plan of Correction Staff removed cleaning solutions from unlocked cabinet and stored them in a locked and secured location during vistit. **Administrator to conduct a in house training to ensure all staff are knowledgable in where and how to properly store disinfectants, cleaning solutions, and poisons. Training log with training information to be submitted to LPA by 10/19/2023. Information must have date of training, who attended (with signatures of participant), who conducted the training and what was reviewed during training.**

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) 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 evidence by: 2 live small insects (roaches) were observed crawling in between R1's facility file. Facility was previously cited on 10/3/22 for same violation.

Official plan of correction

Licensee will contract with professional pest control services. Licensee will submit contract to LPA Ramirez by 8/31/23. Licensee will maintain monthly professional pest control services until insects are eradicated from the facility.

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Interviews with 4 of 4 Residents indicate Staff #2 is working in the facility. Interviews with 2 of 2 Staff also verified Staff #2 is working in the facility. Record review indicate Staff #2 has a criminal record clearance but is not associated to the facility.

Official plan of correction

Licensee shall ensure Staff #2 is not working for the facility until Staff #2 in associated to the facility and provide proof to the department.

Deadline recorded: May 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department.. This requirement is not met as evidenced by: 3 of 4 Residents interviewed indicate Staff #3 works in the facility and 2 of 2 Staff interviewed verified Staff #3 works at the facility. Record review indicate Staff #3 does not have a criminal record clearance and not associated to the facility.

Official plan of correction

Licensee shall ensure Staff #3 is not working for the facility until Staff #3 obtained a criminal record clearance and associated to the facility and provide proof to the department.

Deadline recorded: May 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Hot water temperature measured at 136.4 degree F in the hallway bathroom. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/04/2022 Plan of Correction Licensee shall immediately adjust water temperature to measure within Title 22 guidelines. Note: Water temperature was adjust at time of visit.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: LPA observed 2 live cockroaches in the Resident records Deficient Practice Statement Based on observation, the licensee did not comply with the section cited abovewhich poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2022 Plan of Correction Licensee shall obtain pest control services and provide proof to the department by the POC date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Staff #1, #2 did not have current first aid/CPR training. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2022 Plan of Correction Licensee shall obtain current first aid/CPR training for Stafff #1, #2 and Staff who does not have current first aid/CPR training and provide proof to the department by the POC date.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

Administrator provided staff training on reporting requirements and provided proof of correction to LPA Irra during today's visit.

Deadline recorded: Oct 11, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

97211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

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 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

Deadline recorded: Oct 12, 2021. A deadline is not proof that correction was completed.