198320179-2-7-2025-11-AS-SCIS-DEBVRY-20250228154040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320179
Report Date: 10/03/2024
Date Signed: 02/07/2025 11:58:19 AM

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
09/25/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20240925120845

FACILITY NAME:	SUNRISE OF BEVERLY HILLS		FACILITY NUMBER:	198320179
ADMINISTRATOR:	ZACHARY MICHAEL HOWELL		FACILITY TYPE:	740
ADDRESS:	201 NORTH CRESCENT DRIVE		TELEPHONE:	(310) 274-4479
CITY:	BEVERLY HILLS	STATE: CA	ZIP CODE:	90210
CAPACITY:	127	CENSUS: 73	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	Liza Bond		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not ensure that a resident's incontinence needs were met
Staff do not answer a resident's call button in a timely manner
Staff do not monitor a resident for change in condition

INVESTIGATION FINDINGS:

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**This amended LIC9099, dated 12/09/2024, supersedes the original LIC9099, dated 10/03/2024**
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Thursday, October 03, 2024, upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a risk assessment. Based on the evaluation, the facility is cleared of COVID-19 infection. LPA Bunker met with The facility Nurse Liza Bond. LPA Bunker explained the purpose of today's visit.
The investigation consisted of the following: Interviews were conducted with staff members 1-3 (S1-S3) and residents 1-7 (R1-R7). LPA Bunker asked pertinent questions relevant to the nature of the complaint. S1-S3 and R2-R7 stated that staff ensure that a resident's incontinence needs are met, that the resident's call button is answered in a timely manner, and that the staff monitors residents for changes in their condition. During visits, we toured the facility, including buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats or concerns. No evidence of neglect or abuse was observed during these visits on October 02, 2024, and October 03, 2024.
See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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 11-AS-20240925120845

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE OF BEVERLY HILLS	FACILITY NUMBER: 198320179
	VISIT DATE: 10/03/2024

NARRATIVE

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Continued LIC9099-C page 2
LPA Bunker requested a copy of the personnel report, and resident roster, and reviewed the resident files, including the physician's report, medical records, admission agreement, identification and emergency information, medication records, medication administration records (MARs), medication logs, medical assessments, consent forms, incident reports, appraisal & needs service plan. LPA Bunker requested copies of supporting documents. S1-S2 stated that R1 handles its own medications and medical appointments.

Allegation #1: Staff did not ensure that a resident’s incontinence needs were met
Interviews with staff members S1-S3 (S1-S3) stated that there was no indication in R1's medical records that R1 was experiencing incontinence need. S1-S3 stated that R1 was not receiving incontinence assistance per the resident's needs and services plan. S1-S3 stated that R1’s undergarments were dry, and there was no evidence of R1 sitting in urine overnight. S1-S3 stated that R1 does not receive one-on-one care and that R1 had accidentally fallen after sliding from her bed, which was positioned low to the floor as per the resident’s preference. S1-S3 stated that prior to the fall, staff had just left R1’s room, and R1 was doing well.
Shortly after the fall, a family member called to inform staff. While S3 was still on the phone with the family member, S3 proceeded to R1’s room to provide assistance, and staff promptly called for additional help. The Care Manager responded immediately. S3 stated that a complete body check was conducted for injuries, but at first, R1 refused the body check. Staff observed a discoloration on R1’s left leg. It was unclear whether the discoloration resulted from the fall or was present prior to the fall. S1-S3 stated that R1 reported feeling fine, declined hospital care, and refused medical treatment. S3 states that she and the Care Manager assisted R1 back to bed. The family, responsible party, and physician were promptly notified. S1-S3 emphasized that the fall could not have been prevented by staff. S1-S3 stated that they have maintained open communication with the family and their leadership team, including lengthy meetings lasting up to four hours. S1-S3 stated the facility operates 24/7, 365 days a year, ensuring resident safety at all times.

Allegation #2: Staff do not answer a resident's call button in a timely manner
S1-S3 stated staff consistently respond to residents’ call buttons in a timely manner. The facility adheres to a 10-minute response window or less for assisting residents once a call is placed, whether via the call button or pendant. S1-S3 stated it did not take an hour to help the resident. S1-S3 stated that S3 was in the resident's room when the resident was on the phone with her family member. S1-S3 stated that S3 did respond to the resident's pendant alarm promptly. R2-R7 stated that staff always answer a resident's call button in a timely manner. S1-S3 and R2-R7 denied the allegation. See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20240925120845

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE OF BEVERLY HILLS	FACILITY NUMBER: 198320179
	VISIT DATE: 10/03/2024

NARRATIVE

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Continued LIC9099-C page 3

Allegation #3 Staff do not monitor a resident for changes in condition
S1-S3 stated the facility staff monitors residents' changes in condition. S1-S3 the care staff will alert the Registered Nurse if a resident needs assistance. R2-R7 stated staff monitor residents for changes in condition. When a resident goes to the doctor the Wellness Department provides residents with an envelope for the doctor to complete as a follow-up on the resident's medical condition. S1-S3 and R2-R7 denied the allegation.

Investigation revealed the following:
Staff members 1-3 (S1-S3) interviewed stated that on September 23, 2024 R1's undergarments were dry, and R1 had not sat in urine for 24 hours. R1 agreed that her undergarments were not wet, and she did not sit in urine for hours. R1 physician's report states that R1 has no bowel or bladder impairment and is capable of self-care. S1-S3 stated that on the morning of September 24, 2024, at 4:48 A.M., R1 had accidentally fallen after sliding from her bed. R1 mentioned that after the fall, it took approximately one hour to reach her phone for assistance because it was out of her immediate reach. S1-S3 stated that S3 went to R1's room immediately and R1 did not wait an hour for assistance. S1-S3 stated there were four staff on duty when the incident occurred. S1-S3 stated that S3 responded immediately during both incidents. S1-S3 explained that R1 does not receive one-on-one care and that prior to the fall, staff had just left the resident's room, and R1 was doing well and in stable condition. Shortly after the fall, S3 received a call from R1’s family member informing them of the incident. While still on the phone with the family member, S3 proceeded to R1’s room to provide assistance. S3 stated that she promptly called for help, and the Care Manager responded immediately. Together, S3 and the Care Manager conducted a thorough body check on R1 for injuries, observing a discoloration on R1’s left leg. However, it was unclear whether the discoloration resulted from the fall or was present beforehand. S3 stated they assisted R1 back to bed while still on the phone with the family member. R1 declined medical treatment and refused further assistance. S1-S3 indicated that the fall was unavoidable, as there were no witnesses to the incident, either from staff or residents. Regarding the call button allegation, S1-S3 and R2-R7, stated that the call buttons are answered in a timely manner. S1-S3 stated that the facility adheres to a 10-minute or less response window for assisting residents once a call is made, whether through the call button or pendant. S1-S3 also stated that they monitor residents’ conditions, and any changes are promptly reported to the Registered Nurse (RN) for further action.
See continued LIC9099-C page 4

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240925120845

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE OF BEVERLY HILLS	FACILITY NUMBER: 198320179
	VISIT DATE: 10/03/2024

NARRATIVE

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Continued LIC9099-C page 4

S1-S3 emphasized that Sunrise of Beverly Hills operates on a 24/7 basis. R2-R7 stated that staff members are consistently available to assist and expressed satisfaction with their living conditions at the facility.
S1-S3 and R2-R7 stated that the accommodations provided are comfortable and that the staff is dedicated to ensuring the safety and well-being of all residents. All allegations were denied by S1-S3 and R2-R7.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs, was provided to Assisted Living Coordinator Nancy Maya.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4