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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608842
Report Date: 05/25/2021
Date Signed: 05/26/2021 08:49:19 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2020 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200827133509
FACILITY NAME:SUNNY HILLS ASSISTED LIVING (MEMORY CARE)FACILITY NUMBER:
197608842
ADMINISTRATOR:SUNGNAM PARK "SUSAN"FACILITY TYPE:
740
ADDRESS:8717 WEST OLYMPIC BLVD.TELEPHONE:
(310) 659-4301
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:120CENSUS: 67DATE:
05/25/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Susan Park, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff locked residents in thier room
Facility has bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted telephonically with Susan Park, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 09/04/20 & 05/03/21, LPA Soto interviewed administrator Susan Park. On 05/03/21, LPA Soto interviewed S#2 – S#4, R#1 – 5, and virtually toured the following sections of the facility such as: Rooms 227, 228, 305, & 304, 3rd floor storage room, 2nd floor exercise room, and front office. LPA Soto requested and received the following documents on 05/03/21: Resident Roster, Staff Schedule, and photos of the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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 5
Control Number 11-AS-20200827133509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUNNY HILLS ASSISTED LIVING (MEMORY CARE)
FACILITY NUMBER: 197608842
VISIT DATE: 05/25/2021
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following. For Allegation 1 – Facility staff locked residents in their rooms. Interviews conducted with Administrator and staff; they all deny that the staff locks the residents in their room. Interviews conducted with residents: they are not locked in their rooms.
LPA Soto received photo evidence, where it shows that the staff put a rope made of plastic bags from room 305 to room 304. The photos also show that the makeshift rope was stored in the 3rd floor storage room. LPA virtually compared and confirmed the rooms and storage room with the photos provided. The records concur with the above allegation.

For Allegation 4 – Facility has bed bugs. Interviews conducted staff and residents; they all deny they had bed bugs in the facility. Interview conducted with Administrator, admitted that they did have bed bugs in the facility, in the month of August 2020. The facility treated the problem by spot treating the facility. There were only bed bugs in one room. They treated the room for 1 month and got rid of the bed bugs. LPA received photo evidence that showed resident had bed bug bites on her left hand. Interview and record obtained concur with the allegation above.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

An exit interview was conducted with Susan Park, Administrator and a hard copy and appeal Rights provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2020 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200827133509

FACILITY NAME:SUNNY HILLS ASSISTED LIVING (MEMORY CARE)FACILITY NUMBER:
197608842
ADMINISTRATOR:SUNGNAM PARK "SUSAN"FACILITY TYPE:
740
ADDRESS:8717 WEST OLYMPIC BLVD.TELEPHONE:
(310) 659-4301
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:120CENSUS: 67DATE:
05/25/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Susan Park, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Facility staff left residents in soiled clothing for an extended period of time
Facility staff failed to assist residents with toileting needs
INVESTIGATION FINDINGS:
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3
4
5
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7
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9
10
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13
Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted telephonically with Susan Park, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 09/04/20 & 05/03/21, LPA Soto interviewed administrator Susan Park. On 05/03/21, LPA Soto interviewed S#2 – S#4, R#1 – 5, and virtually toured the following sections of the facility such as: Rooms 227, 228, 305, & 304, 3rd floor storage room, 2nd floor exercise room, and front office. LPA Soto requested and received the following documents on 05/03/21: Resident Roster, Staff Schedule, and photos of the facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20200827133509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUNNY HILLS ASSISTED LIVING (MEMORY CARE)
FACILITY NUMBER: 197608842
VISIT DATE: 05/25/2021
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following. For Allegation 2 – Facility staff left residents in soiled clothing for an extended period of time. The interviews conducted with Administrator and staff, deny leaving that the staff leave the residents in soiled clothing for an extended period of time. Interviews with conducted with residents, they all stated that they have never been left in soiled clothing. The interviews conducted do not concur with the above allegation.

For Allegation 3 – Facility staff failed to assist residents with toileting needs. The interviews conducted with Administrator and staff; all agree that the staff do assist residents with toileting needs. Interviews conducted with residents, they all stated that they are always helped with their toileting needs. The staff is very helpful. The interviews conducted do not concur with the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

An exit interview was conducted with Susan Park, Administrator, and a hard copy was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20200827133509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNNY HILLS ASSISTED LIVING (MEMORY CARE)
FACILITY NUMBER: 197608842
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2021
Section Cited
CCR
87468.1(2)
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87468.1(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on observation and interviews the facility had bed bugs which poses a potential health, safety to persons in care.
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Administrator to create a plan in which they will take certain precautions and procedures to avoid this in the future. Email, fax or mail POC by 06/01/21 to LPA Soto.
Type B
05/25/2021
Section Cited
CCR
87468.1(3)
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87468.1(3)3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.his requirement is not met as evidencedby: based on obervation and interviews the facility locked residents in
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Administrator to create a plan in which they will take certain precautions and procedures and includes training for staff to avoid this in the future. Email, fax or mail POC by 06/01/21 to LPA Soto.
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their rooms. Which poses a potential health, safety to persons in care.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5