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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197609684
Report Date:
08/06/2021
Date Signed:
08/06/2021 01:59:24 PM
Unsubstantiated
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
05/24/2021
and conducted by Evaluator
Wendell Smith
PUBLIC
COMPLAINT CONTROL NUMBER:
31-AS-20210524134532
FACILITY NAME:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
ADMINISTRATOR:
SAVELLA, JEFFREY
FACILITY TYPE:
740
ADDRESS:
8001 SUNNYBRAE AVE
TELEPHONE:
(323) 455-7821
CITY:
WINNETKA
STATE:
CA
ZIP CODE:
91306
CAPACITY:
6
CENSUS:
6
DATE:
08/06/2021
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Jeffrey Savella
TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer a resident's medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Wendell Smith made an unannounced subsequent visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit.
Regarding the allegation above it is alleged that the facility did not administer resident #1 (R1) medication as prescribed. LPA conducted a previous visit on 5/25/21 where LPA conducted a file review of R1's facility file and obtained copies of pertinent information. LPA previously interviewed R1's responsible person and the facility administrator. Information from interviews reveal that R1 came to the facility on 4/19/21 from Canyon Oaks Nursing facility. R1 was taking prednisone tablets when they came to the facility but only had a few days supply when they came to the facility. Facility administered the remaining dosage and then R1's responsible person brought more from home which apparently expired on 4/17/21 so the facility did not give the expired medication. Administrator stated that they informed R1's responsible person that the prednisone they brought to the facility was expired and that they needed his prescription refilled. R1's responsible person acknowledged that they were the one responsible for getting refills for R1's medication but stated they were not aware that R1's prednisone needed refilling.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME
:
Cassandra Harris
LICENSING EVALUATOR NAME
:
Wendell Smith
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/06/2021
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
3
Control Number
31-AS-20210524134532
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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
VISIT DATE:
08/06/2021
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
Based on information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time. There is not enough information to state that it was the facilities fault that R1's medication was refilled on time. Exit interview conducted.
SUPERVISORS NAME
:
Cassandra Harris
LICENSING EVALUATOR NAME
:
Wendell Smith
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/06/2021
LIC9099
(FAS) - (06/04)
Page:
2
of
3