Inspection Reports for Summer House at Ladera Heights

The visit was an unannounced case management evaluation conducted in conjunction with Complaint Control #11-AS-20191113101336 to investigate allegations regarding the use of restraints on a resident.

The investigation substantiated that Resident #1 was restrained to the bedrails using cloth restraints around the wrists, which posed an immediate health and safety risk. Staff admitted to restraining the resident to prevent removal of a Foley catheter and scratching wounds. A citation was issued for violation of personal rights regulations.

The allegation that a resident was restrained by the hands to the bedrails was found to be substantiated based on evidence gathered, interviews, and records reviewed.

An unannounced complaint investigation was conducted in response to an allegation that the licensee was restricting resident's visitations.

The investigation found that although there were delays in responding to visitors, residents were not restricted from having visitors. The allegation was determined to be unsubstantiated due to insufficient evidence to prove the alleged violation.

The allegation was that the licensee was restricting resident's visitations. Interviews with staff and residents confirmed that visitors were allowed, despite some delays. The allegation was found to be unsubstantiated.

An unannounced annual visit was conducted using the CARE Inspection tool to evaluate compliance with licensing requirements for the facility.

The facility was generally found to be clean, safe, and well-maintained with proper infection control and medication management practices. However, deficiencies were cited related to missing staff training records, incomplete resident files, outdated emergency drill documentation, and an outdated emergency plan.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not ensure a resident was able to return to the facility after hospitalization.

The investigation included interviews with staff and residents, a facility tour, and document reviews. The allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the alleged violation occurred. A technical violation was issued.

The complaint alleged that after a resident was transferred to the Emergency Department, attempts to contact facility staff were unsuccessful, resulting in the resident being transferred back to the hospital. The investigation found no evidence to support this allegation and it was unsubstantiated.

The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for a facility serving clients with dementia ages 60 and above.

The facility was found to have several deficiencies including expired first aid documentation for staff, lack of auditory device on a sliding exit door, missing personal property forms for some clients, facility walls in poor condition, expired administrator certification, and lack of proof of liability insurance. Plans of correction were requested with due dates.

An unannounced complaint investigation was conducted following allegations that staff were not keeping medications and dangerous items in a safe and locked location.

The investigation found no evidence to support the allegations. Interviews with staff, residents, and a witness confirmed that medications and dangerous items were stored securely in locked cabinets, inaccessible to residents. No deficiencies were cited and the allegations were deemed unsubstantiated.

The complaint was unsubstantiated due to insufficient evidence to prove the alleged violations regarding unsafe storage of medications and dangerous items.

The visit was a follow-up on deficiencies issued during a prior visit on 7/21/2023 to verify correction of cited issues.

During the follow-up visit, some deficiencies remained uncorrected, including unlocked medication cabinets and hot water temperature issues. Some hazardous items were removed from resident-accessible areas, but locks on medication cabinets were present but not engaged.

The visit was a Case Management visit conducted to follow up on the Annual inspections processed on prior visits dated 3/28/23 and 5/19/23, to gather information to complete those Annuals.

Several deficiencies were observed including hot water temperature in the kitchen exceeding the allowed maximum, unlocked medication cabinet, improper bed linens, postural supports without physician prescription, and accessible toxic cleaning supplies posing immediate health and safety risks to residents.

The inspection visit was an unannounced annual required visit to continue the evaluation of the facility using the new CARE Inspection Tool.

Two deficiencies were cited during the inspection: water temperature in the bathroom and kitchen was found to be 131.5°F, exceeding the allowed maximum of 120°F, posing an immediate health and safety risk; and the facility oven was not operational, posing a potential health and safety risk. Four technical assistance advisories were also issued.

An unannounced annual required visit was conducted using the new CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.

Several deficiencies were observed including excessively high hot water temperature, unlocked storage of knives and scissors, lack of a non-slip mat in the bathroom, and a non-operational oven. The annual inspection was not completed due to time constraints and will be continued at a later date.

An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.

The facility was found to be sanitary, appropriately furnished, and compliant with Title 22 regulations. Five deficiencies were cited during the inspection, and four technical assistance advisories were issued. Infection control practices including screening protocols and sanitizing stations were observed.

The inspection was a Case Management visit conducted as part of the annual review to cite the facility for deficiencies.

Five deficiencies were cited during the visit, including issues with hot water temperature exceeding safe limits, unsafe storage of cleaning chemicals, maintenance problems such as a dresser without handles, incomplete and outdated resident medication records, and a resident housed in a converted garage shared with staff posing health and safety risks.

The visit was conducted to deliver a Case Management – Deficiencies evaluation report in conjunction with Complaint Control #11-AS-20191113101336, following observations related to the restraint of a resident.

The investigation found that Resident #1 was restrained to the bedrails using cloth restraints around the wrists, which was substantiated as a violation of personal rights. Staff admitted to restraining the resident to prevent removal of a Foley catheter and scratching wounds, despite repeated instructions from a home health nurse to remove the restraints.

The allegation that a resident was restrained by the hands to the bedrails was found to be substantiated based on evidence gathered, interviews, and records reviewed.

The visit was an unannounced complaint investigation conducted in response to allegations of severe neglect resulting in a resident developing a pressure injury and failure to address the resident's change in medical condition.

The investigation substantiated the allegations of severe neglect and failure to address the resident's change in medical condition. Resident #1 had multiple pressure injuries upon admission and during care, and the facility retained the resident despite prohibited health conditions. The resident was hospitalized multiple times and expired on 12/04/2019.

The complaint investigation was substantiated. Allegation #1 of severe neglect resulting in a resident developing a pressure injury was substantiated. Allegation #2 that the facility failed to address the resident's change in medical condition was also substantiated. An enhanced civil penalty determination is pending related to serious bodily injury.