197608478-11-24-2021-29-AS-DPEA-C9Y6YA-20211222201312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608478
Report Date: 11/24/2021
Date Signed: 11/24/2021 04:30:28 PM

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2020 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20200616104430

FACILITY NAME:	SUNRISE ASSISTED LIVING OF WOODLAND HILLS		FACILITY NUMBER:	197608478
ADMINISTRATOR:	COLAMARIA, THOMAS		FACILITY TYPE:	740
ADDRESS:	20461 VENTURA BLVD		TELEPHONE:	(818) 346-9046
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	127	CENSUS: 64	DATE:	11/24/2021
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Diana Guevara for Benito del Toro		TIME COMPLETED:	04:28 PM

ALLEGATION(S):

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Lack of supervision resulting in resident sustaining a fall and fracture

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced subsequent complaint visit to the above facility. The purpose of the visit is to conclude an investigation initiated by LPA Brian Balisi on 06/17/2020. LPA met with Staff Diana Guevara and while ED Benito del Toro was on the phone during the final findings reading. Entrance interview conducted.

Information was received that Resident #1 (R1) sustained an unwitnessed fall as a result of negligence by facility staff. During the initial visit on 06/17/2020 between 2:30pm and 03:15pm, an interview with the facility administrator and a virtual physical plant tour were conducted by LPA Balisi. Investigator Dennis Seng from Community Care Licensing Division’s Investigations Branch (IB) conducted the investigation. Investigation consists of interview with the reporting party on 7/13/2020; interview with R1’s responsible person, and R1 on 07/14/2020; interview with random facility residents and other witnesses on 8/18; interview with Executive Director and other staff on 08/18/2020; 8/28/2020 and 09/01/2020.

Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

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 29-AS-20200616104430

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE ASSISTED LIVING OF WOODLAND HILLS	FACILITY NUMBER: 197608478
	VISIT DATE: 11/24/2021

NARRATIVE

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Continued from LIC 9099...

Interviews conducted and facility records reviewed reflected that R1 was a fall risk and had suffered several reported falls at the facility in 04/2020; one fall in 05/2020 and another fall on 6/14/2020. On 06/01/2020 the victim was moved to the Remanence unit of the facility. It was further revealed that facility did try to mitigate R1s falls by lowering the bed position, using fall mats, physician-approved bed rails, and place the resident in the common areas of the Remanence floor so that staff could supervise them. It was further revealed that R1 had a history of not complying with staff and would get up or bend down to pick up objects on the floor without alerting staff.

Information gathered revealed that on 06/14/2020, at approximately 3:30pm, R1 was assisted to the restroom and escorted back to a sofa chair located in a common area of the Remanence floor. Staff reported that they turned around for one instant to assist another resident and heard R1 scream. Staff turned and found R1 was lying on the floor from an apparent fall. Staff assessed R1 and 911 was called. Although, R1 did fall at the facility and sustained a hip fracture there is not enough evidence to say R1 fell as a result of staff negligence. Interview conducted with other witnesses reported that they regularly visit the facility and have not seen evidence of any lack of supervision. Random residents interviewed reported feeling safe at the facility. Based upon all the information obtained, the department does not have sufficient information to support the allegation. Therefore, the above allegation “Lack of supervision resulting in resident sustaining a fall and fracture” is deemed unsubstantiated at this time.

Exit interview conducted. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

LIC9099 (FAS) - (06/04)

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