Inspection Reports for
Summer House at Ladera Heights

The facility was found to have several Type B deficiencies including lack of grab bars in all resident shower areas, staff without updated First Aid certificates, missing health screenings for staff, incomplete medical assessments for residents, missing pre-admission appraisal for one resident, and failure to conduct quarterly fire drills.

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 investigation found that Resident #1 was restrained to the bedrails using cloth restraints around the wrists while wearing gloves, which was substantiated as a violation of personal rights. Staff admitted the restraints were used to prevent the resident from removing a Foley catheter and scratching wounds. A citation was issued for this deficiency.

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 However, deficiencies were cited related to missing staff training records, incomplete resident files, outdated emergency drill documentation, and an outdated emergency plan.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 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 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 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.

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.

Multiple deficiencies were observed including hot water temperature 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.

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.

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

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.

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 facility was observed to be sanitary, appropriately furnished, and compliant with Title 22 regulations. Five deficiencies were cited during the inspection, and four technical assistance notes were issued.

The complaint investigation was substantiated. Allegations included severe neglect resulting in a resident developing a pressure injury and failure to address the resident's change in medical condition. The resident had multiple pressure injuries documented and was hospitalized multiple times before expiring. Facility staff were aware of the resident's condition but failed to provide appropriate care and observation.

The investigation substantiated both allegations, finding that the facility retained a resident with prohibited health conditions including multiple pressure injuries and failed to properly observe and address changes in the resident's medical condition. The resident subsequently expired. Deficiencies were cited related to prohibited health conditions and failure to observe changes in resident condition.