198602549-12-2-2021-11-AS-EMAZ-CHMVAQ-20220825161620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602549
Report Date: 12/02/2021
Date Signed: 12/02/2021 01:45:36 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2020 and conducted by Evaluator Stephanie Cifuentes

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201113162356

FACILITY NAME:	SUNRISE AT PALOS VERDES		FACILITY NUMBER:	198602549
ADMINISTRATOR:	KELLY JACOBS		FACILITY TYPE:	740
ADDRESS:	25535 HAWTHORNE BLVD		TELEPHONE:	(310) 377-7425
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	115	CENSUS: 75	DATE:	12/02/2021
		UNANNOUNCED	TIME BEGAN:	10:44 AM
MET WITH:	Kelly Jacobs-ExecutiveDirector		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff spoke inappropriately to resident

INVESTIGATION FINDINGS:

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This report serves as an amendment to report created 1/11/2021. This report supersedes the complaint investigation findings reflected on report created 1/11/2021.

Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today’s complaint investigation was conducted via Zoom with Kelly Jacobs, the facilities Executive Director. LPA explained the purpose of this telephonic visit is to gather information regarding the complaint allegations.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

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-20201113162356

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
MONTERY PARK, CA 91754

FACILITY NAME: SUNRISE AT PALOS VERDES	FACILITY NUMBER: 198602549
	VISIT DATE: 12/02/2021

NARRATIVE

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The investigation consisted of the following: On 11/20/2020 LPA interviewed facility administrator and was given a tour of the facility grounds. LPA was shown residents bedroom, lobby, dining room, kitchen, activity room, outdoor patio and private dining room. On 12/9/2020 LPA interviewed facility staff and residents. LPA requested and received the following documents: Case notes and physicians’ assessment for Resident 1 (R1), staff roster and client roster, termination letter for staff 1 (S1).

Regarding the allegation: Staff spoke inappropriately to resident

The investigation revealed the following:

On 11/20/2020 LPA Cifuentes toured facility grounds with staff via zoom and requested copies of files.

On 11/20/2020 LPA spoke with administrator Kelly Jacobs regarding staff and client interactions. Per administrator Jacobs, Resident 1 (R1) reported to her that staff 1 (S1) had spoken inappropriately to her. Administrator investigated incident by interviewing staff 1 (S1) and staff 2(S2), who was with S1 during incident with R1. After speaking with both staff, the administrator believed S1 had spoken inappropriately to the resident and the staff was released from employment from the facility. LPA Cifuentes received a copy of written termination notice for S1 and reviewed it on 1/5/2021. Per the written notice, staff member was terminated after an investigation concluded that S1’s “behavior and actions while assisting a resident were not in-line with Sunrise’s Principles of Service and demonstrated that she did not work in a cooperative manner.” During the investigation, LPA Cifuentes interviewed several residents and staff. On 12/9/2020 LPA Cifuentes interviewed residents 1 through resident 7. Of the residents interviewed 6 out of 7 stated facility staff had not spoken to them inappropriately and went on to say that interactions with staff were positive. Staff were interviewed on 12/9/2020. Of those interviewed, 8 out of 8 staff responded that they had not spoken rudely when interacting with a resident and also stated that interactions with resident were positive.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted, and a copy of the report and appeal rights were given to Kelly Jacobs, Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20201113162356

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
MONTERY PARK, CA 91754

FACILITY NAME: SUNRISE AT PALOS VERDES	FACILITY NUMBER: 198602549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/16/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities To be free from punishment, humiliation, intimidation, abuse or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	POC corrected on todays visit 12/2/2021. Facility conducted investigation and terminated employee for inappropriate conduct.
	8 9 10 11 12 13 14	Through interview LPA found that S1 had spoken inappropriately to R1. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC9099 (FAS) - (06/04)

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