198600321-10-5-2021-11-AS-MVAO-C9BRAR-20211202115135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600321
Report Date: 10/05/2021
Date Signed: 10/05/2021 07:32:53 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, 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
08/02/2021 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210802085931

FACILITY NAME:	SUNNYSIDE RETIREMENT CENTER		FACILITY NUMBER:	198600321
ADMINISTRATOR:	ANGELES, JENNYLYN		FACILITY TYPE:	735
ADDRESS:	22713 SOUTH VERMONT AVENUE		TELEPHONE:	(310) 320-3318
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY:	48	CENSUS: 42	DATE:	10/05/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jennylyn Angeles - Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident was exposed to hazardous chemicals while in care

INVESTIGATION FINDINGS:

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On 10/05/2021, Licensing Program Analyst (LPA) Don Senaha and LPA Gail Johnson conducted a subsequent visit to deliver complaint findings.

On 08/10/2021 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. The complaint investigation was conducted with Jennylyn Angeles/Administrator.
Investigation consisted of the following: Interviews with Administrator, clients (C1-C11) and staff (S2-S5). LPA also requested copies of the following documents: client roster, staff roster and service records. A plant inspection of the facility was conducted.

Allegation findings:

LPA met with Administrator Jenny Angeles and explained the purpose of the visit.LPA conducted interviews with clients (C1-C11) and staff (S1-S5) on 08/10/21. Clients (C2-C11) stated they have never

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210802085931

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: SUNNYSIDE RETIREMENT CENTER	FACILITY NUMBER: 198600321
	VISIT DATE: 10/05/2021

NARRATIVE

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been exposed to hazardous chemicals. Staff (S1-S5) have never been exposed to hazardous chemicals. On 08/10/21 at 1:59pm, LPA observed no odor or chemical residue in client (C1) room. On 08/10/21, LPA observed no odor or chemical residue when walking around the facility’s perimeter. LPA observed outdoor perimeter area to have no hazards and allows for easy passage. LPA obtained information from Bright View Gardener (W1) they do not use any spray that poses a risk to humans.

Based on LPA’s interviews conducted, records reviews and observations, the preponderance of evidence standard has not been met.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated
An exit interview was conducted with Jenny Angeles, and a hard copy was provided for signature.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

LIC9099 (FAS) - (06/04)

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