Indian Summer Place

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted a subsequent visit to continue the annual inspection. LPAs met with Administrator, Samantha Alex, to explain the reason of the visit. LPAs inspected the following domain of the CARE tools. Staffing: Per licensee, there is sufficient staffing at the facility and backup staff if needed. Staff employed have fingerprint clearance and associated to the facility. Personnel Records-Training: LPA reviewed 3 staff files and all documents are in file. Staff have current CPR/first aid training. Resident Records-Incident Reports: LPA reviewed 5 resident files and the following documents are found - admission agreements, Identification & Emergency Information, Physician's Report, Consent forms, Resident rights, and Safeguards for Personal Property/Valuables form. Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Incidental Medical & Dental: The medications are centrally stored and locked in the kitchen drawers. Resident medications were reviewed and there were discrepancies found. Resident #3 did not have the physician's order for medication Risperidone. Resident #4 had an extra bubble pack of Lorazepam which appeared to be given with the other meds. Resident with Special Needs: There are currently no residents with a prohibited or restricted health condition or using oxygen. A deficiency was issued today. Exit interview was held. A copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Oct 3, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 9/16/25. LPA arrived unannounced and met with Administrator, Samantha Alex. The purpose of the visit was explained. The facility is licensed to serve ambulatory residents, ages 60 and above. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools and inspected the following: Infection Control: Facility has submitted an Infection Control plan and continuing to follow the plan. Operational Requirement: There are (5) ambulatory residents residing at the facility. The liability insurance was not provided to LPA during the visit. Physical Plant and Environmental Safety: The facility is a single-story home consisting of (3) shared resident bedrooms, (1) staff room, (3) bathroom, 2 living rooms, dining area, kitchen. The back yard has a shaded area with table and chairs. The bathrooms required grab bar and non-skid mat. Knives and cleaning supplies are stored inaccessible to residents. There are no items obstructing the walkways. Residents' Right : The facility has all the required postings. The facility also has internet service. Planned Activities: The facility has sufficient space to accommodate both indoor and outdoor activities. Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable. No residents are on a modified diet. Disaster Preparedness: The facility has an Emergency Disaster Plan. LPA issued a technical advisory for administrator not reviewing the form annually. Residents with Special Health Needs: There is (1) resident receiving home health services. No resident has a restricted health condition or prohibited health condition. LPA will return another day to continue the annual inspection. A deficiency was issued today. An exit interview was held and a copy of this report, LIC809D, and appeal rights were given to the administrator.the state’s words, verbatim · CDSS document, Sep 16, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Staff Henry Scott and explained the reason of the visit. The following domains were completed during the visit: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice hand washing constantly. The facility has submitted an Infection Control plan in place. 2. Operational Requirement: The facility is licensed to serve elderly residents age 60 and above. Fire clearance granted for six (6) ambulatory residents only. Currently all the residents are ambulatory. Liability Insurance documentation was not provide to LPA during the visit. Facility does not serve residents with Dementia. 3. Physical Plant and Environmental Safety: The facility is a single-story home located in a residential area. A tour of the facility includes: 2 living rooms, dining area, kitchen, laundry room with pantry, (4) bedrooms of which (1) is a designated staff room, 3 bathrooms ( of which 1 is attached to the Staff room), back yard with required shaded area and outdoor furnishing. LPA inspected all three resident bedrooms: required furniture and beddings were observed as well as sufficient lighting and closet space. Bathrooms observed to be clean, sanitary and in a good working condition. The bathroom also has required grab bar and non-skid mat. The hot water temperature tested in resident bathroom is 119 degrees F which is within the Title 22 regulation. The toxic cleaning supplies are stored and inaccessible to residents. The facility has a land line telephone system. Fire alarms and C02 alarms observed. The walkway, passageway and patio are free of obstruction. 4. Staffing: The facility has sufficient staffing in the facility. Staff has updated CPR training. The administrator and care giving staff live in the facility; therefore staff is available and present overnight. Continued on LIC 809-C 5. Personnel Record Training: All the staff files are stored. The facility staff are all over 18 years old, associated with the facility and criminal background clearance. The facility administrator is Samantha Alex and her administrator certificate is expired. 6. Resident Records-Incident Reports: The resident files are centrally stored. LPA reviewed four (4) resident files and they all have the required documents which included: face sheet, pre-placement appraisal information, appraisal/needs and service plan, admission agreement, updated physician report and TB test, ambulatory status and medication list. Two (2) Resident files were not present for review. 7.Residents' Right : The facility has all the required postings. The facility also has internet service shall provide at least one internet access device for resident use to face time with their families or entertainment. 8. Planned Activities: The facility does have sufficient space to accommodate both indoor and outdoor activities 9. Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable. All the food are stored probably. No residents are on modified diet that prescribed by the doctor. 10. Incident Medical and Dental: The resident medication are centrally stored and locked in the kitchen cabinet. LPA inspected all six (6) residents medications on hand. Centrally stored medication list for (2) of (6) residents were not completed to match prescription orders. Administrator will also provide medical and dental transportation if needed. 11. Disaster Preparedness: The facility has a disaster plan in place. The facility has two alternative temporary shelter location. Facility was provided notice to update the disaster plan to the updated form provide by the department. 12. Residents with Special Health Needs: There is (1) resident with home health services. LPA reviewed and observed the home health file. There are no residents on hospice. No resident is under restricted health condition or prohibited health condition. Per the completion of the Inspection Tool, deficiencies are being cited for todays visit. Please see attached 809-D pages. Appeal rights discussed and provided. Exit Interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to ensure that deficiencies cited on 10/24/23 have been corrected. LPA met with Administrator Samantha Alex and explained the purpose for the visit. 87303(e)(2): on 10/13/23 LPA conducted the initial annual visit and observed water temperature in clients restrooms to be 128.6-129.5 degrees F, which was outside of the required range of 105-120 degrees F. During subsequent visit on 10/24/23 LPA observed water temperature in 1 out of 2 client restrooms to be at 127.2 degrees F, on both visits facility was cited Maintenance and Operation: 87303(e)(2). During todays visit LPA tested both client restrooms water temperature and they measured at 137.2 and 140.5 degrees F, Administrator lowered water temperature during visit. Civil penalty is being assessed. 87309(a): on 10/13/23 LPA conducted the initial annual visit and observed cleaning cleaning solutions in an unlocked cabinet under client bathroom sink, on subsequent visit 10/24/23 LPA observed knives to be stored in unlocked pantry and medication cabinet was unlocked within the unlocked kitchen. On both visits facility was cited Storage Space: 87309(a). During todays visit LPA toured facility, no cleaning solutions were found under clients restroom sinks, medicine cabinet was also observed and was locked. Kitchen was observed to have cleaning solutions stored under kitchen sink and were unlocked (administrator stated that the lock was lost), knives were observed in a separate cabinet and were also unlocked, during visit Administratror Samantha Alex locked both cleaning supply and knife storage cabinets. Civil penalty is being assessed. Exit Interview conducted and copy of the report and appeal right was provided to Administrator Samantha Alex. Administrator refused to sign LIC421FC's and 809.the state’s words, verbatim · CDSS document, Nov 3, 2023

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Tena Herrera conducted the continuation of the required annual inspection. LPA arrived unannounced and met with Samantha Alex (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 6 ambulatory elderly residents ages 60 and above. The facility is a single-story home located in a residential area. A tour of the facility includes: 2 living rooms, dining area, kitchen, laundry room with pantry, 4 bedrooms (2 client bedrooms, 1 administrators’ bedroom, 1 administrators daughters bedroom), 3 bathrooms (2 client and 1 Staff bathroom), back yard with required shaded area and outdoor furnishing. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. However, there was not an Infection Control Plan on file or accessible for review during initial (this is being cited on 809D). Operational Requirements: The facility has an approved fire clearance and outdoor activity area that is shaded and furnished for outdoor use. Staffing: Administrator Certificate and qualifications were not readily available during visit, this will be cited on 809D page. Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and training. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility does not have the required Residential Care Facility for the Elderly (RCFE) Complaint Poster this will be cited on the 809D page. Resident Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. (Continued on 809-C) Physical Plant & Environment Safety: Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. During initial visit LPA observed bedding to be out of regulation, during subsequent visit bedding was still out of regulation with there being blanket and mattress pad only on one bed (missing bed sheets) [administrator stated resident does not wish to have sheets on bed] and blanket with sheet on other (missing mattress pad) [administrator stated that they use the plastic covering that comes with the mattress upon purchase as a mattress pad which is not compliant with regulation] this will be cited on 809D page. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested in resident bathroom during initial visit and was out of range (citation was issued) during subsequent visit water temperature was measured and was out of range at 127.2 degrees F the required range is 105-120 degrees F (new citation being issued today for water temperature). During subsequent visit cleaning supplies and toxins were centrally stored and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged. During initial visit it was stated that the kitchen remains locked to prevent residents from accessing medications and sharps that are stored within the kitchen, staff had indicated the only reason the kitchen was unlocked was because LPA was conducting tour, during subsequent visit LPA observed kitchen doors to be open and unlocked, LPA asked to see where sharps/knives were stored and they were stored in an unlocked cabinet as well as medication unlocked (citations will be issued on 809D). Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Health Related Service: Staff designated to administer medication has the proper training on file. Medication is properly labeled and are centrally stored in a cabinet and are in their original containers (during subsequent visit LPA observed medication cabinet to be unlocked, cited on 809D). During the initial visit, LPA reviewed 3 clients’ medication no issues were observed. Incidental Medical & Dental: Licensee assists in arranging medical and dental services to residents in care. (continued on 809-C) Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: There are currently no resident at this facility with special health needs. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D). Exit interview held and a copy of the report was provided to Administrator Samantha Alex.the state’s words, verbatim · CDSS document, Oct 24, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Samantha Alex (Administrator) and Henry Scott (staff) who assisted with the visit, the purpose for the visit was explained. FACILITY LICENSED TO SERVE ELDERLY RESIDENTS AGE 60 AND ABOVE. FIRE CLEARANCE APPROVED FOR 6 AMBULATORY RESIDENTS. During visit LPA toured the facility, reviewed client and staff records, reviewed client medications and facility files. There were 2 type A deficiencies observed during todays visit, one being hot water temperature and the other being disinfectants and cleaning supplies being accessible to clients in care. Details of these citations will be documented on the 809D page. Due to time constraints, LPA will continue this inspection at a later date. LPA will return to continue the required 1-year annual inspection. Exit Report held and a copy of this report and appeal rights were provided to Administrator Samantha Alex.the state’s words, verbatim · CDSS document, Oct 13, 2023