197608842-5-26-2023-11-AS-JHAD-D5K2A9-20240523171305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608842
Report Date: 05/26/2023
Date Signed: 05/26/2023 04:06:46 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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 Wendy Gibbs

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 ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	120	CENSUS: 85	DATE:	05/26/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Steve Cho		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not properly trained
Medication records are inaccurate

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 staff in-service training and etc.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
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: 1 of 5

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
EL SEGUNDO, 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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Staff are not properly trained

According to the allegation, new staff are not being fully trained, and Med Techs are not properly trained or certified. On 05/20/23, at 8:45am, LPA Gibbs and Alvizar and LPM Margaryan conducted interviews with staff. Information received revealed they have not received proper training for all activities of daily living, to assist overall facility population.

Observed revealed that staff are spoon feeding some residents and have not received any training by a qualified medical professional on the proper way to feed residents. Interviews with Med Techs revealed they did not receive initial medication training by the qualified medical professional. Med Techs watched a manager distribute medications, and then they repeat what they observe, while a manager shadows them. A manager shadowing med tech was not qualified medical professional. At the time of this visit Administrator was unable to provide specific training tools, or other pertinent records test results to verify that the medication training provided to the med techs meet Title 22 Regulations and/or Health and Safety Code.
During this visit at 12:00pm all training records were reviewed and the information gathered from the documents were not sufficient enough to verify that staff received all required trainings as per Title 22 regulations.
Based on LPAs observation, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Medication records are inaccurate
According to the allegation, the medication record for distribution of medications is not accurate. On 05/26/23, at 10:53am, LPA Gibbs and Alvizar and LPM Margaryan inspected a Medication Room to review the resident medication supply and the Medication Record. Upon review of a randomly selected resident’s medication supply and medication record review, LPA and LPM observed medication record to be inaccurate. The information documented on medication record was not consistent with the number of pills dispensed to the resident. After additional review of the medication record, it was observed that no resident’s medication record was signed off on 05/20/23 for medications distributed.
Based on LPAs observations, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiencies were cited under California code of Regulation, Tittle 22, Division 6 & Chapter number 8, 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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
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 5

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
EL SEGUNDO, 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 06/20/2023 Section Cited CCR 87411(d)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance	1 2 3 4 5 6 7	Administrator agrees to provide staff with job specific trainings. Proof of correction will be submitted to LPA Gibbs at Wendy.Gibbs@dss.ca.gov
	8 9 10 11 12 13 14	Based on file review, observation, and interviews the licensee failed to provide on the job training to staff. Investigation revealed staff did not receive job specific trainings which poses a potential health andsafety hazard for residents in care.	8 9 10 11 12 13 14
Type B 06/20/2023 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506 Resident Record (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.	1 2 3 4 5 6 7	Administrator agreed to conduct on the job training to medication staff and update all residents MAR for 05/20/23. Proof of correction will be submitted to LPA Gibbs at Wendy.Gibbs@dss.ca.gov
	8 9 10 11 12 13 14	Based on file review, and observation the licensee failed to maintain a complete and current record for residents in care. During record review LPA observed the MAR for 05/20/23 is incomplete. Which poses a potential health and safety hazard for residents in care.	8 9 10 11 12 13 14

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 M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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 Wendy Gibbs

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 ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	120	CENSUS: 85	DATE:	05/26/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Steve Cho		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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9

Facility does not have a qualified administrator

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
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: 3 of 5

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
EL SEGUNDO, 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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Facility does not have a qualified administrator

According to the allegation, the facility does not have a properly trained and qualified Director or Administrator. On 05/26/23, LPA Gibbs and Alvizar and LPM Margaryan, reviewed Administrator documents. Administrator provided Personal Record (LIC501), current CPR (ex 08/26/24), Administrator Certificate (ex 09/10/25), copy of Drivers License, Fingerprint Clearance, Board of Resolutions Letter, and Facility Designation Letter.

Unsubstantiated Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
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: 4 of 5