<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609532
Report Date: 07/14/2021
Date Signed: 07/14/2021 01:51:55 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2019 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20191107163312
FACILITY NAME:SUNRISE ASSISTED LIVING OF WEST HILLSFACILITY NUMBER:
197609532
ADMINISTRATOR:EDITH KENNEDYFACILITY TYPE:
740
ADDRESS:9012 TOPANGA CANYON ROADTELEPHONE:
(703) 273-7500
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:90CENSUS: 56DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marilu MampellTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not meeting residents needs
Staff left residents in soiled diapers for extended periods of time
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in regards to the above allegations.

As part of this investigation, LPA interviewed 6 staff members and 2 residents, in addition to reviewing facility records, on 11/14/19; interviewed 5 staff members and three residents on 11/18/19; interviewed a staff member telephonically on 7/13/21; interviewed 2 staff members, 2 residents and a witness (W1) on 7/14/21.

Allegation #1, that "Staff is not meeting residents needs" has been substantiated based on the records reviewed and interviews conducted. The "Performance Counseling & Improvement Plan" dated 7/11/19 for Staff #1 (S1) that LPA obtained on 11/14/19 states that S1 "did not respond to being paged multiple times on...walkie radio on 7/10/19...did not ensure communication and resident and team member safety."
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 4
Control Number 31-AS-20191107163312
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE ASSISTED LIVING OF WEST HILLS
FACILITY NUMBER: 197609532
VISIT DATE: 07/14/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
2/9 of the caregivers interviewed on 11/14/19, 11/18/19, and 7/14/21 were able to corroborate that S1 was ignoring resident pendant calls, as did W1 on 7/14/21 at 12:47PM. The allegation is substantiated.

Allegation #2, that "Staff left residents in soiled diapers for extended periods of time" has been substantiated based on the records reviewed and interviews conducted. The "Performance Counseling & Improvement Plan" dated 7/11/19 for Staff #1 (S1) that LPA obtained on 11/14/19 states that S1 "did not follow department policy when assisting...on Friday, 07/05/2019. Resident....called and asked to be changed. [S1] did not immediately respond to...request to be changed and instead communicated with...of..last brief change. When [S1] did assist...with changing brief it was at...recliner instead of the bathroom." 2/9 of the caregivers interviewed on 11/14/19, 11/18/19, and 7/14/21 were able to corroborate that S1 was ignoring resident pendant calls, as did W1 on 7/14/21 at 12:47PM. The allegation is substantiated.


Report reviewed, signed and delivered. Exit interview conducted, appeal rights issued, deficiencies on 9099D page.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20191107163312
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE ASSISTED LIVING OF WEST HILLS
FACILITY NUMBER: 197609532
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/28/2021
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
87464(f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
1
2
3
4
5
6
7
Staff training will be conducted regarding responding to resident requests for help, proof of training will be provided to LPA.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

Based on record review and interviews conducted, the facility did not ensure that Resident 1 (R1) was changed upon request which poses a potential risk to clients in care.
8
9
10
11
12
13
14
Request Denied
Type B
07/21/2021
Section Cited
CCR
87468.1(a)(1)
1
2
3
4
5
6
7
87468.1(a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.



This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility will review its current census-based staffing and pendant call response times for the purpose of providing LPA with the following: the average pendant response time, what the goal response time is, and a signed statement confirming that staffing is and will continue to be sufficient to meeting the goal response time.
8
9
10
11
12
13
14
Based on record review and interviews conducted, the facility did not ensure that S1 was responding to resident calls for help which poses a potential risk to 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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2019 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20191107163312

FACILITY NAME:SUNRISE ASSISTED LIVING OF WEST HILLSFACILITY NUMBER:
197609532
ADMINISTRATOR:EDITH KENNEDYFACILITY TYPE:
740
ADDRESS:9012 TOPANGA CANYON ROADTELEPHONE:
(703) 273-7500
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:90CENSUS: DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:TIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff shoved resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in regards to the above allegations.
As part of this investigation, LPA interviewed 6 staff members and 2 residents, in addition to reviewing facility records, on 11/14/19; interviewed 5 staff members and 3 residents on 11/18/19; interviewed a staff member telephonically on 7/13/21; interviewed 2 staff members, 2 residents and a witness (W1).

Allegation #1, that "staff shoved resident," has been unsubstantiated based on the records reviewed and interviews conducted. None of the counseling memos provided to LPA on 11/14/19 and 7/14/21 indicated physical abuse from Staff #1 (S1), and 13/14 staff interviews, 6/7 client interviews and the witness interview conducted all failed to corroborate this allegation. On 11/18/19 Executive director Edith Kennedy refused to provide an additional internal investigation notes to LPA.
Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 4