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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608842
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:56:18 PM

Substantiated


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
10/10/2022 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221010123746
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: 85DATE:
05/26/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Co- Administrator, Steve ChoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
1. Facility does not change food menu.
2. Activities are not provided to the resident's.
3. Inadequate staffing to meet the needs of the resident's in care.
INVESTIGATION FINDINGS:
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Licensing program Analysts (LPAs) Antonia Alvizar, Mario Leon , Wendy Gibbs and Licensing Program Managers (LPMs) Naira Margaryan and Ulysses Coronel conducted unannounced subsequent complaint visit to the facility. LPAs and LPMs met the Administrator, who was informed that this visit was conducted to continue an investigation of the complaint allegations, previously initiated on 10/19/2022
Initial visit was conducted by LPAs Antonia Alvizar, Mario Leon, Wendy Gibbs and Licensing Program Manager (LPM) Ulysses Coronel. On 10/19/22 approximately at 10:10am, LPAs and LPM inspected the facility which included the bedrooms, bathrooms, common areas, kitchen, dining room and medication room. LPAs Alvizar and Leon conducted interviews between 10-30am and 12:00pm at which time, they spoke with the Administrator and other facility staff present at the time of visit. In addition, LPAs interviewed 8 out of 71 randomly selected residents, LPA also gathered facility records, including but not limited to physician report, pre-placement appraisal, need and service plan, residents and staff roster, food menu, activity calendar, sign in sheets for staff training, schedules for resident shower, incontinent care and house keeping log.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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 12
Control Number 11-AS-20221010123746
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: 05/26/2023
NARRATIVE
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1. Facility does not change food menu
It was alleged that the facility menu never changes. Residents have no other choices except what is on menu.
An interview with facility cook and other kitchen staff revealed that they are following facility menu. Residents interviewed during this investigation did not address any concerns about menu.
Prior to this visit on 05/15/2023 at 2:30pm, LPA Alvizar and LPM Margaryan reviewed facility menu gathered at the time of initial visit and noted that Five (05) out of seven (07) days, during breakfast, residents were served ham, egg, and cheese sandwiches and pancake and toast for remaining two (02) days. No second choices where available for residents.
Based on interview, observation, and record review there is a sufficient information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

2. Activities are not provided to the residents
It was alleged that facility residents are not participating to the activities. The staff assigned to provide activities does not have required qualifications.
During interview, the Administrator verified that the facility does not have qualified Activity Personnel. At the time of initial visit, no activates were provided to facility residents.
Residents interviewed during investigation indicated that they are not attending activities.
Based on interviews, and observation there is a sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 12
Control Number 11-AS-20221010123746
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: 05/26/2023
NARRATIVE
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3. Inadequate staffing to meet the needs of the resident's in care
During the visit on 05/26/23 between 8:30am and 11:00am LPM Margaryan, LPAs Alvizar and Gibson spoke with the three (03) out of Five (05) caregivers and one (01) housekeeper. 1 caregiver was working on the 1st floor, 2 caregivers on the 2nd and 2 on the 3rd floor.

Interviews revealed that each caregiver is assisting 8-10 residents requiring extensive assistance, which include incontinent, care, shower assistance helping residents on wheelchair, feeding assistance, light cleaning of the rooms, talking residents to walk.

Based on the information provided by the caregivers, each of them is spending at least 3hrs to provide incontinent care (10-15min per person, 3 times per shift), 1.5-2 hours to provide escort assistance to 3-5 residents, (5min per resident, 3 times a day to and from meal service). Caregivers also spend at least 1hr taking 3-5 residents to walk (10 min average- 1-2 times a day), In addition staff is spending 1h to provide feeding assistance about 2-4 residents (15min or more per resident). Each caregiver provides 1-2 shower assistance approximately 20-25 minutes. After assisting residents, with their activities of daily living, all caregivers are doing daily cleaning in the rooms; taking out the trash, dirty diapers, making beds, which takes at list 40-50min. Information received revealed that caregivers also assist residents that may require stand by and/or reminder assistance. However, based on interviews, observation, review needs and services plan of current population and staff schedule, it was concluded that within 8 hour shift staff is only assisting residents requiring extensive care.
Overall investigation revealed that additional qualified personnel is needed, to assist overall population with all their activities of daily living. The Administrator indicated that they are planning to hire additional staff to ensure that all residents needs are met.
The information and evidence obtained during this investigation, is sufficient enough to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Per California Code of Regulation, Title 22, Division 6, Chapter 8, following citations were issued and recorded on LIC9099D

No immediate health and safety hazard were noted during this visit. Exit interview is conducted, Appeal rights discussed and a copy of report was issued.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 12
Control Number 11-AS-20221010123746
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: 05/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
87555(b)(6)
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General Food Service Requirements. (b) The following food service requirements shall apply: (6) In facilities for 16 persons or more, menu shall be written at least 1 week in advance & copies of the menu... shall be dated & kept on file...
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The Administrator will provide a new copy of the facility menu, drafted and reviwed by the Licensed dietitian or Nutritionist.
POC must be completed by POC due date.
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 This requirement is not met as evidenced by. LIcensee did not ensure that the facility menu is meeting food services requirement. 5 out of 7 day resident are served the same food for breakfast . This poses a potential personal rights violation to residents in care.
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Type B
05/26/2023
Section Cited
CCR
87219(f)
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Planned Activities (f) In facilities licensed for 50 persons or more, 1 staff member shall have full-time responsibility to organize, conduct, planned activities... The activities shall be written, planned in advance.. be available to all residents…
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Based on observation and records provided by the Administrator, facility hired Activity Director and LPAs observed residents were participating in the activities.
Therefore, this citation is cleared during this visit.
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 This requirement is not met as evidenced by. Based on observation & record review Licensee did not provide planned activities as required. This posses potential personal right risk to resident 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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 12
Control Number 11-AS-20221010123746
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: 05/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by.
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The Administrator will provide written plan of action explaining what steps they are going to do to retain sufficient number of qualified personnel to assist current population.

POC must be completed by POC due date.
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 Based on interviews, record review Licensee did not insure to have sufficient
number of compitenat staff. During 8 hours shift staff is only assisting residents requiring extensive care. This possess potential Health & Safety risk to residents in care.
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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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 12
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
10/10/2022 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221010123746

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: 85DATE:
05/26/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Steve ChoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
4. Resident was left in a soiled diaper for a long period of time.
5. Staff humiliating resident's.
6. Staff yells at resident's.
7. Resident's are without linens.
8. Staff not providing laundry services.
9. Resident's are not given a shower.
10. Staff not keeping resident's information confidential.
INVESTIGATION FINDINGS:
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Licensing program Analysts (LPAs) Antonia Alvizar, Mario Leon, Wendy Gibbs and Licensing Program Managers (LPMs) Naira Margaryan and Ulysses Coronel conducted unannounced subsequent complaint visit to the facility. LPAs and LPMs met the Administrator, who was informed that this visit was conducted to continue an investigation of the complaint allegations, previously initiated on 10/19/2022
Initial visit was conducted by LPAs Antonia Alvizar, Mario Leon, Wendy Gibbs and Licensing Program Manager (LPM) Ulysses Coronel. On 10/19/22 approximately at 10:10am, LPAs and LPM inspected the facility which included the bedrooms, bathrooms, common areas, kitchen, dining room and medication room. LPAs Alvizar and Leon conducted interviews between 10-30am and 12:00pm at which time, they spoke with the Administrator and other facility staff present at the time of visit. In addition, LPAs interviewed 8 out of 71 randomly selected residents and gathered facility records, including but not limited to physician report, pre-placement appraisal, need and service plan, residents and staff roster, food menu, activity calendar, sign in sheets for sign in sheets for staff training, schedules for resident shower, incontinent care and house keeping log.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 12
Control Number 11-AS-20221010123746
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: 05/26/2023
NARRATIVE
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4. Resident was left in a soiled diaper for a long period of time.
It was alleged that staff doesn’t provide scheduled diaper change to the resident #13 (R13). R13 always smells bad.
Direct care staff interviewed during investigation, stated that they change residents’ diaper as needed. The residents interviewed during investigation did not express any concerns regarding their incontinent care provided by the facility. During facility inspection LPAs observed caregivers attending residents to provide incontinent care. The rooms inspected during investigation had no smell of urine. As per LPAs observation all residents appeared to be clean and groomed.
Based on interviews, inspection and observation, there is an insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

5. Staff humiliating residents.
6. Staff yells at residents.
It was alleged that during diaper change staff is humiliating residents and yells at residents. During interview, Administrators stated they received no complains from the residents regarding staff yelling or humiliating them.
All staff members interviewed during investigation denied humiliating residents or yelling at them, Residents interviewed during investigation indicate that the staff is very nice, and no one yells at them or humiliates them. LPAs observed residents during interviews and did not notice any signs of distress.
Based on interviews and observation there is no sufficient information to support above noted allegations. Hence, the allegation is UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 12
Control Number 11-AS-20221010123746
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: 05/26/2023
NARRATIVE
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7. Residents are with out linens.
8. Staff is not providing laundry services.

Concerns were addressed that staff does not provide linens to the residents. There are full of laundry left behind in the closet with urine and residents’ laundries are not completed as it was scheduled.
To investigate these allegations, on 10/19/22 LPAs inspected randomly selected residents’ rooms. LPAs checked residents’ beddings and all mattresses were covers with padding and linens. The residents’ closets were inspected, and LPAs did not observe dirty laundry hidden in the closets.
Staff revealed that linens are being changed once a week. For incontinent residents they change beddings as frequently as needed. Facility has specific staff assigned to laundry services. They are washing dirty linens daily. Facility has laundry schedule for residents and staff follows the schedule. Residents interviewed during investigation addressed no concerns about changing their beddings and/or laundry services.

Prior to this visit, on 05/15/23 at 2:00pm, LPA Alvizar reviewed Facility laundry schedule and noted that all residents have specific day to wash their clothes and to change linens. Residents’ clothes are washed as per schedule and linens are washed every day.

Based on inspection, observation, interviews and record review, there is an insufficient information to verify the allegation. Therefore, allegations are UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 12
Control Number 11-AS-20221010123746
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: 05/26/2023
NARRATIVE
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9. Residents are not given showers
It was alleged that staff did not provide residents shower assistance according to schedule.
To investigate these allegations LPAs spoke with the Administrator and other facility staff. Interviews revealed that each resident is being showered at list once a week. Incontinent residents may receive showers more frequently.
The residents interviewed during investigation had no issues and concerns regarding their shower assistance. Prior to this visit, 05/15/2023 at 2:00pm LPA Alvizar reviewed residents shower schedule, which indicated that during morning and afternoon shift, staff provides shower assistance to 8-10 residents daily.

Based on interviews observation and record review, there is no sufficient information to verify the allegation. Therefore, the allegations are UNSUBSTANTIATED at this time.

10. Staff not keeping residents’ information confidential
It was alleged that Staff discuss residents’ personal health conditions in front of others. Interview of Administrator and co-administrator revealed that they keep residents information confidential. Med tech and other staff verify the information provided by the Administrators. Residents did not disclose any concerns about breach of confidentiality. Residents interviewed during investigation did not disclosed an concerns about breach of confidentially. While inspecting physical plan LPAs observed that the residents files were in Business Office and locked at all times.

Based on interviews and observation there is not enough pertinent information to verify validity of the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 12
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
10/10/2022 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221010123746

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: 85DATE:
05/26/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Steve ChoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
11. Emergency food storage area is unsanitary
12. Facility serving expired food to resident
13. Staff not serving an adequate amount of food to resident
14. Residents service plan is not updated
15. Physician’s reports were not reviewed prior to admission
16. Facility did not notice changes in resident’s condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing program Analysts (LPAs) Antonia Alvizar, Mario Leon , Wendy Gibbs and Licensing Program Managers (LPMs) Naira Margaryan and Ulysses Coronel conducted unannounced subsequent complaint visit to the facility. LPAs and LPMs met the Administrator, who was informed that this visit was conducted to continue an investigation of the complaint allegations, previously initiated on 10/19/2022
Initial visit was conducted by LPAs Antonia Alvizar, Mario Leon, Wendy Gibbs and Licensing Program Manager (LPM) Ulysses Coronel. On 10/19/22 approximately at 10:10am, LPAs and LPM inspected the facility which included the bedrooms, bathrooms, common areas, kitchen, dining room and medication room. LPAs Alvizar and Leon conducted interviews between 10-30am and 12:00pm at which time, they spoke with the Administrator and other facility staff present at the time of visit. In addition, LPAs interviewed 8 out of 71 randomly selected residents and gathered facility records, including but not limited to Physician report, pre-placement appraisal, need and service plan, residents and staff roster, food menu, activity calendar, sign in sheets for staff in-service training and etc.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 10 of 12
Control Number 11-AS-20221010123746
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: 05/26/2023
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11. Emergency food storage is unsanitary.
12. The facility is serving expired food to residents.
13. Staff not serving adequate amount of food to the residents.

The complaint was alleging, that the food served to the residents on the 3rd floor is expired. No sufficient amount of food is served to the residents. Emergency food storage is not clean.
Interview of Administrator and kitchen staff revealed that they don’t keep expired food in the kitchen. Cook always makes the meal from fresh food and they provide enough portions of the food to everyone. Residents may ask for seconds if needed. Emergency food storage is being checked frequently.
Residents interviewed during this investigation stated that they like facility food and verified that they may ask for seconds.

During initial visit facility food storage and available perishable and nonperishable food were reviewed, and LPAs did not observe any expired food in the food storage and in the refrigerators.

At the time 11:32AM of this visit LPAs observed the meal served during lunch hours and the portions of the food served to residents were adequate in quantity and variety.
Based on inspection, observation and interviews, there is no sufficient information or evidence to verify the allegations.

Therefore, the allegations are UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 11 of 12
Control Number 11-AS-20221010123746
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: 05/26/2023
NARRATIVE
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14. Residents service plan is not updated.
15. Physician’s reports were not reviewed prior to admission.
16. Facility did not notice changes in resident’s condition.

It was alleged that the Administrator does not review residents’ physician report prior to admission. Residents need and service plan are not updated to identify changes in residents’ condition.

Interviews of Administrator and co-Administrator revealed that prior to residents’ admission, residents’ physician reports are reviewed, pre-placement appraisal was competed. Need, and service plan is updated as frequently as needed.
Randomly selected residents Physician reports and need and service plan were reviewed by LPA Alvizar on 05/15/23 at 3:30pm. LPA noted that both documents physican report and needs and services plan were updated at least annually. Health information from the physician reports were documented on preplacement appraisal form. Per LPA review, updated appraisal/need and service plan identify few changes in residents’ conditions.

Based on interviews and record review, there is no supporting information to establish preponderance of evidence, Hence the above noted allegations are UNSUBSTANTIATED at this time. No immediate health and safety hazard where noted during this visit.
Exit Interview was conducted. Copy of report was provided to the Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 12 of 12