197608842-10-2-2023-11-AS-NMAN-CWKLJS-20231013084825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608842
Report Date: 05/31/2023
Date Signed: 10/02/2023 12:42:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
11/14/2022 and conducted by Evaluator Antonia Alvizar

COMPLAINT CONTROL NUMBER: 11-AS-20221114120901

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: 69	DATE:	05/31/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Licensee does not ensure a supply of basic hygiene products are available for residents in care
Staff do not ensure that resident has an adequate supply of medication while in care

INVESTIGATION FINDINGS:

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This is the addendum of the initial Licensing Report conducted on 11/22/2022. The report was changed to add additional pertinent information.

Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced complaint visit to investigate the above noted allegations. This visit was assisted by the Administrator Woo (Jason) Park and Co-Administrator Steve Yong Jin Cho.
During the course of the investigation LPA Alvizar inspected the physical plant approximately at 9:00am.
Prior to conducting a tour of physical plant, LPA requested residents and staff rosters, other facility records, including but not limited to the schedule of Incontinent Care assistance, a fee schedule for the basic and additional services provided to the residents and medication administration documents. LPA interviewed the Administrators and four (04) staff at approximately 9:30am. At approximately 11:20am LPA Alvizar spoke with seven (07) out of sixty-nine (69) residents including resident #1(R1) in addition LPA Alvizar spoke with the Witness #1 (W1), who had knowledge of the services provided to R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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 3

Control Number 11-AS-20221114120901

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: 05/31/2023

NARRATIVE

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Allegation 1: Licensee does not ensure a supply of basic hygiene products are available for residents in care.

It was alleged that the facility is not providing hygiene supply to the residents. Family is to provide products included in the Incontinence Care supply; service such as wipes, cleaning spray and creams.
Staff interviews revealed that facility is providing hygiene products, such as soap, shampoo, body wash and etc. However, providing Incontinent Care supply is not part of the hygiene items that should be provided by the facility. Although, as per the facility Personal Care Program, Incontinent Care products are provided by resident and/or their responsible party(s), as a courtesy, facility is providing diapers and in lieu of wipes they use washcloths. Residents’ family and/or responsible parties may provide wipes based on their preferences.
Interviews of residents did not address any concerns regarding incontinent supply (diapers wipes and creams).
During facility inspection, LPA Alvizar observed incontinent supply closet and reviewed facility hygiene supply. The facility has sufficient quantity and variety of the hygiene items.
A review of facility records verified the information revealed from the staff.
Based on inspection, observation, interviews and record review, there is an insufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20221114120901

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: 05/31/2023

NARRATIVE

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Allegation 2: Staff do not ensure that resident has an adequate supply of medication while in care.

It was alleged that resident #1 (R1) ran out of hypertension medication, nobody refills order or request order from the doctor.
An interview of Administrators revealed that they are conscious of providing medication to residents. The medication refill is once a month. They check the medication supply periodically and when it gets low, they reorder or refill the medications. Upon arrival, they review new orders and if something is missing, staff reports to pharmacy, and they send it right away.
Four (04) out of (04) staff verified the information received from the Administrator. They indicated that they review, log, and prepare all medication immediately after receiving from pharmacy. At times, if needed they request emergency medication supply for new residents. The request to the doctor can be made by phone, fax or via- text.
The residents interviewed during this investigation, did not express any concerns regarding their medication assistance, W1 who was private caregiver for one of the residents stated, that they did not notice any problems with medication assistance.
A review of medication records and medication supply did not reveal any information to support the allegation.
Based on interviews, available evidence, observation, and records reviewed there is not enough corroborating information to support the allegations. Although the allegations may have happened or is valid, there is no supporting evidence to determine validate the complaint. Therefore, the allegation is deemed unsubstantiated at this time.

No immediate health and safety hazard were noted during this visit.

An exit interview was conducted, and a copy of report was issued.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC9099 (FAS) - (06/04)

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