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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608474
Report Date: 10/14/2021
Date Signed: 10/19/2021 09:40:53 AM

Substantiated


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
09/17/2021 and conducted by Evaluator Angelica Arambulo
COMPLAINT CONTROL NUMBER: 31-AS-20210917161143
FACILITY NAME:SUN CARE HOMESFACILITY NUMBER:
197608474
ADMINISTRATOR:STEPHANIE FLORESFACILITY TYPE:
740
ADDRESS:18725 SHOENBORN STREETTELEPHONE:
(818) 384-7456
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 6DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Emma ParicaTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff engaged in a physical altercation in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced subsequent complaint investigation. The LPA met with administrator to deliver the findings.

It was alleged that Facility staff engaged in a physical altercation in the facility. LPA conducted interviews with staff, administrator and residents. The physical altercation was between two staff regarding missing cream supply. The residents were having their lunch meal and could hear what was happening. Both staff are no longer working at the facility and alternate staff are scheduled. Based on the information gathered the allegation is Substantiated.

Citation issued, appeal rights given, exit interview conducted. The report shall be emailed to administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica ArambuloTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20210917161143
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: SUN CARE HOMES
FACILITY NUMBER: 197608474
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2021
Section Cited
CCR
87468.1
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87468.1 Personal Rights of residents in all facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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The administrator shall make sure staff are trainied in the personal rights violation of residents while in their presence. The staff was given an inservice training regarding resident rights.
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This requirement is not met as evidence by incident retported that two staff had a physical altercation at the facility. Administrator was not present but did report to facility as soon as possible. Staff that was injured did seek medical attention and brought to the hospital by the administrator.
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Type B
CCR
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica ArambuloTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2