045002389-5-1-2023-25-AS-KHOS-CRGJZL-20230503072944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002389
Report Date: 05/01/2023
Date Signed: 05/01/2023 10:10:17 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2022 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20221227101816

FACILITY NAME:	SUNSHINE ASSISTED LIVING-THE COTTAGE		FACILITY NUMBER:	045002389
ADMINISTRATOR:	LARRY KREPELKA		FACILITY TYPE:	740
ADDRESS:	1468 SUN MANOR		TELEPHONE:	(530) 877-3363
CITY:	PARADISE	STATE: CA	ZIP CODE:	95969
CAPACITY:	17	CENSUS:	DATE:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	LARRY KREPELKA		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff did not prevent a resident from sustaining injuries due to falling multiple times.
Staff are not meeting the resident’s needs.

INVESTIGATION FINDINGS:

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Donna Gurriere and Sarah Benson, Licensing Program Analysts were in contact and met with Larry Krepelka, Administrator.

LPA Gurriere and Benson completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. LPA Gurriere ensured that hand sanitizer was applied before entering the facility.

continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221227101816

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SUNSHINE ASSISTED LIVING-THE COTTAGE	FACILITY NUMBER: 045002389
	VISIT DATE: 05/01/2023

NARRATIVE

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Staff did not prevent a resident from sustaining injuries due to falling multiple times.
During the investigation, the administrator and five staff persons were interviewed. In addition, various documents were obtained for reviewed. Documents included the resident’s Physician’s Report, Admission Agreement, Care and Needs Assessment and incident reports.

During the interview process, it was reported that the resident wanted to be independent and did not want to advise the staff that he was in need to get up, or use the toilet; therefore, he tried to get himself out of bed and suffered a fall. Staff reported that they were available to assist him and that he refused. Staff stated that pressure mats and guard rails were provided for the resident’s bed, which helped out some. Staff stated that due to the resident’s independent nature, they could not prevent the falls that the resident had. There is not enough evidence to support that the resident’s falls were due to the staff persons lack of supervision.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

Staff are not meeting the resident’s needs.
During the investigation, the administrator and five staff persons were interviewed. In addition, various documents were obtained for reviewed. Documents included the resident’s Physician’s Report, Admission Agreement, Care and Needs Assessment and incident reports.

During the interview process, it was reported that the resident was somewhat difficult due to his dementia status. Staff stated that they met the resident’s needs by assistance with sponge baths, repositioning him, toileting, grooming and care and supervision. Staff advised that hospice services were implemented, which provided additional assistance to the resident. There is not enough evidence to prove that the resident’s needs were not met.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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