197603807-3-18-2023-31-AS-NMAN-CQ5PW4-20230321114007

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603807
Report Date: 03/18/2023
Date Signed: 03/18/2023 02:44:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200810160037

FACILITY NAME:	SUNRISE AT STERLING CANYON		FACILITY NUMBER:	197603807
ADMINISTRATOR:	JOHNSON, MICHELLE M		FACILITY TYPE:	740
ADDRESS:	25815 MCBEAN PKWY		TELEPHONE:	(661) 253-3551
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	140	CENSUS: 123	DATE:	03/18/2023
		UNANNOUNCED	TIME BEGAN:	11:42 AM
MET WITH:	Debbie Gutierrez - Reminiscence Coordinator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff not supervising resident resulting in multiple falls and injury/injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA met with Reminiscence Coordinator Debbie Gutierrez and explained the reason for the visit.

LPA conducted physical plant tour at 11:46 AM, requested copy of facility documents relevant to the investigation at 12:00 PM, reviewed records between 12:00 PM to 1:45 PM. It was alleged that Resident #1 (R1) had fallen on 08/07/20 and 08/08/20 and sustained a skin tear behind R1's ear. LPA's record review on 03/04/23 between 12:01 PM to 2:00 PM and today between 12:00 PM to 1:45 PM revealed that R1 had an infected wound on right foot since 04/14/20, became infected and continuously deteriorating. On 04/17/20, R1 was brought to hospital for further evaluation and eventually had the foot amputated on 05/11/20 and returned to the facility on 05/13/20. Upon R1's return, R1 was put on Home Health service for R1's wound.

(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

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 31-AS-20200810160037

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE AT STERLING CANYON	FACILITY NUMBER: 197603807
	VISIT DATE: 03/18/2023

NARRATIVE

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(continued from LIC 9099-C)

Further review also revealed that from the time R1 returned to the facility, R1 was re assessed and put on higher level of care and provided assistance with but not limited to, mobility, dressing, grooming and toileting. R1 was even put on a 1:1 companion for 72 hours upon return based upon the recommendation of the facility staff. R1 had a physician's order to use a hospital bed dated 05/07/20. Further review also revealed that on the Halo rail was checked by maintenance on 08/10/20. LPA's interview with staff on 03/04/23 between 10:00 AM to 12:00 PM, revealed that from the time R1 was adjusting to current medical status (amputation) and confused most of the time so R1 kept on sitting on the edge of the bed like R1 used to prior to amputation, which made R1 slide from the bed and fall on the floor bottoms first. Further interview with staff revealed that due to this behavior of R1, a fall mat was placed beside R1's bed and eventually the Halo rail so R1 had something to hold on and avoid falling on the floor.

Based on the information gathered during this and prior visit, the facility put all the necessary protocol to prevent or alleviate the chance of R1 from falling, the allegation therefore is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC9099 (FAS) - (06/04)

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