198601662-5-26-2023-28-AS-RORN-CT2PCD-20230622111145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601662
Report Date: 05/26/2023
Date Signed: 05/26/2023 02:05:12 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2023 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230522144030

FACILITY NAME:	SUNRISE ASSISTED LIVING AT SAN MARINO		FACILITY NUMBER:	198601662
ADMINISTRATOR:	KIMBERLY SANCHEZ		FACILITY TYPE:	740
ADDRESS:	83332 HUNTINGON DR		TELEPHONE:	(626) 292-7800
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	74	CENSUS: 47	DATE:	05/26/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kimberly Sanchez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff do not ensure reporting requirements are met
Staff did not ensure copies of resident records were provided to the residents responsible party in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Kimberly Sanchez and explained the reason for the visit.

The investigation consisted of: On 05/24/23, LPA received copies of Unusual Incident/ Injury Reports (LIC 624) dated 01/26/23 and 01/30/23 from LPA Galarza. On 05/26/23, LPA conducted an interview with Administrator Kimberly Sanchez and Staff 1 (S1). LPA also conducted a telephone interview with Resident 1's (R1) Authorized Representative (R1 AR). R1 was not interviewed as they are no longer a resident of the facility. LPA also received a copy of email records request made to facility on 03/28/23 from R1 AR via email.

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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 28-AS-20230522144030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING AT SAN MARINO	FACILITY NUMBER: 198601662
	VISIT DATE: 05/26/2023

NARRATIVE

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Investigation revealed the following: Regarding allegation, Staff do not ensure reporting requirements are met, it is alleged that R1 had two falls at the facility on 01/23/23 and 01/28/23 and facility staff only contacted R1 AR by phone to report the falls and did not follow up with verbal and emailed requests for written incident reports from R1 AR regarding both falls. Based on record review and interviews conducted the findings indicate that on 01/23/23 and 01/28/23 former resident (R1) sustained falls inside the resident's room. According to staff, R1 fell in their room both falls dated (01/23/23 & 01/28/23). Both were reported to Community Care Licensing (CCL) as well as to R1 AR by telephone. In addition, Administrator stated that R1 AR did request written incident reports for both falls and they were not provided to R1 AR.

For allegation, Staff did not ensure copies of resident records were provided to the residents responsible party in a timely manner, it is alleged that a request for R1's medical records was made to facility staff via email on 03/28/23 and additional follow up emails were also sent and R1 AR was not provided with requested records. R1 did not return to the facility after they were hospitalized on 01/28/23 and was subsequently moved out of the facility on 03/17/23. Interview with R1 AR revealed that as of 05/26/23 they have not received the requested documents from the facility and only received other pharmacy documents that do not contain the requested information. They stated that the request was emailed on 03/28/23 as well as on different dates after initial request. R1 AR stated that the request was clear and specified what was being requested. Administrator stated that R1 AR requested copies of internal documents that could not be provided. S1 stated that they thought that they provided R1 AR with the requested documents and would follow up and ensure that they provided R1 AR with the requested medical records.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code Chapter 3.2 Residential Care Facilities for the Elderly, Article 02.5 Resident's Bill of Rights & Title 22, Division 6 Chapter 8 Article 04. Operating Requirements.

An exit interview was conducted with Administrator Kimberly Sanchez. A copy of the report an appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230522144030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING AT SAN MARINO	FACILITY NUMBER: 198601662
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/02/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified ... below. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a	1 2 3 4 5 6 7	Administrator shall review Title 22 Regulations 87211 and submit a written plan on steps the facility will take in the future related to any incident which threatens the welfare, safety or health of any resident. In addition, staff shall receive in-service training on reporting requirements and documentation.
	8 9 10 11 12 13 14	resident by staff or other residents, or unexplained absence of any resident. This requirement was not met by evidence of: On 01/23/23 and 01/28/23, R1 sustained falls and was sent to the hospital, written report was not provided to R1 AR and only provided to CCL. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 06/02/2023 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies.	1 2 3 4 5 6 7	Administrator shall develop and implement a policy and procedure to include California Health and Satefy Code regulation, 1569.269, as to how this facility will handle requests for residents records in a timely manner. Additionally, Administrator shall train the designated personnel on this policy and procedure and include proof of this training to
	8 9 10 11 12 13 14	This requirement was not met by evidence of: Based on interviews and record review R1 AR request for R1's medical records were not provided to authorized representative within two business days. Facility only provided a copy of documents that did not contain the requested medical records. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	LPA by POC due date.

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC9099 (FAS) - (06/04)

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