134604417-8-24-2023-08-AS-DPOL-CV8RTE-20230831131810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 134604417
Report Date: 08/24/2023
Date Signed: 08/24/2023 01:39:14 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2022 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20221103085230

FACILITY NAME:	SONRISA VILLA INC.		FACILITY NUMBER:	134604417
ADMINISTRATOR:	GUEVARA, ITZEL		FACILITY TYPE:	740
ADDRESS:	708 E. 5TH ST.		TELEPHONE:	(760) 756-3285
CITY:	HOLTVILLE	STATE: CA	ZIP CODE:	92250
CAPACITY:	175	CENSUS: 103	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	01:34 PM
MET WITH:	Gabriela Zamora, Manager		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Neglect/Lack of Supervision resulted in injury to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by Gabriela Zamora, Manager. LPA identified herself and disclosed the purpose of the visit and elements of the findings with the Manager.

The Department investigated the above listed complaint allegation. The investigation consisted of a tour of the facility, interview with staff, residents, and other outside sources, and records review.

Interviews conducted revealed that C1 was hospitalized on March 20, 2022 to April 5, 2022 and was unable to return back to living on their own and was not able to live with family members. C1 was authorized by outside sources to be released to Sonrisa Villa Inc in Holtville on April 13, 2023. On April 14, 2022 C1 was picked up from the hospital and transported to get medications filled and clothing from outside sources, then to Sonrisa Villa Inc. At approximately 10:00 pm on April 16, 2022 outside sources were notified of hospitalization of C1 after several attempts earlier doing the day.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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 08-AS-20221103085230

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SONRISA VILLA INC.	FACILITY NUMBER: 134604417
	VISIT DATE: 08/24/2023

NARRATIVE

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Residents interviewed did not have firsthand knowledge of incident that occurred. Resident verified window screens had been recently placed on windows in residents rooms and along with locks on the windows; there were no screens or locks on North or South hallway windows according to resident. Residents that were outside of the facility and noticed C1 on the ground, but did not witness how C1 got there.

Staff interviewed were not witnesses to the incident that occurred. It was revealed that C1 did not get the "special" attention needed as the facility was in the process of hiring additional staff. Staff stated that C1 was "acting" normal and nothing deemed unusual. Staff stated that C1 tried to leave facility on April 14, 2022 the night C1 arrived but was re-directed. Staff stated on April 16, 2022 med tech notified emergency response team 9-1-1.

Outside source records reviewed dated 04/16/2022: Trauma Notes: BIBH S/P fall from a second story building approximately 20-25 feet. Per by standers patient lander headfirst onto pavement. Per flight crew patient was intubated at approximately 1900 hours. Patient had schizophrenia since age 21, but was functional on medications until a few months ago, when they deteriorated and admitted to mental health facility, then discharged to assisted living with family absence, and patient jumped from second floor due to all their SCZ symptoms and delusions recurring.

Based on the evidence, interviews conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

An exit interview was conducted with Gabriela Zamora, Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Manager and her signature on this report confirms receipt of the Licensee Rights.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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