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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602549
Report Date: 03/19/2024
Date Signed: 03/19/2024 02:18:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2022 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221012141025
FACILITY NAME:SUNRISE AT PALOS VERDESFACILITY NUMBER:
198602549
ADMINISTRATOR:KELLY JACOBSFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVDTELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:115CENSUS: 71DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Kelley KoulTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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9
Staff did not seek medical attention for resident on a timely basis.
Staff did not respond to requests for communication about resident in care in a timely manner.
Staff are not conducting a reappraisal on resident as necessary.
INVESTIGATION FINDINGS:
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On 03/19/24, at 09:30am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent unannounced visit to the facility and was greeted by Kelley Koul, Director. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above.

The investigation consisted of the following: An initial complaint visit was completed by LPA Jeremiah Randle on 10/19/22. A subsequent visit was completed by LPA Perry Scott on 03/19/24. LPAs investigated the allegations mentioned in this complaint; and conducted interviews with residents and staff. Resident Roster, Staff Roster, Service Plan, Physicians report, Health Care Provider information, and ID/Emergency information were obtained from the facility.

The investigation revealed the following: Allegation #1-Staff did not seek medical attention for resident on a timely basis.

Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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 3
Control Number 11-AS-20221012141025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SUNRISE AT PALOS VERDES
FACILITY NUMBER: 198602549
VISIT DATE: 03/19/2024
NARRATIVE
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The details of the complaint alleged that the facility staff did not seek medical attention for R1 in a timely manner. It was reported that R1 was admitted to the hospital on 10/7/2022 and returned to the facility after tests. And on 10/9/2022 it was reported that R1 complained of pain, but nothing was done. On 03/19/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R9) regarding the allegation. R1 was not interviewed because R1 has since passed away. LPA attempted to contact the family member but was not able to with the current information on file. 2 of 4 staff denied the allegation that Staff did not seek medical attention for resident on a timely basis. Staff (S1-S2) stated that they have no knowledge of this former resident. Whereas staff S3-S4 stated that the resident always received timely medical care and they kept R1s responsible person who had Power of Attorney and R1s Primary Care Physician apprised of R1s medical needs. All staff stated that all residents receive timely medical attention.

LPA interviewed R1-R9 about the allegation that Staff did not seek medical attention for resident on a timely basis. 8 of 9 residents denied the allegation and stated that whenever they need medical attention, they do receive it in a timely manner from the staff.

Based on interviews, there is insufficient evidence to support the allegation that the Staff did not seek medical attention for resident on a timely basis. 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 Unsubstantiated.

Allegation # 2- Staff did not respond to requests for communication about resident in care in a timely manner.

The details of the complaint alleged that the facility staff stop responding to requests from interested parties for information on R1 and R1s care. On 03/19/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R9) regarding the allegation. R1 was not interviewed because R1 has since passed away. LPA attempted to contact the family member but was not able to with the current information on file.

4 of 4 staff denied the allegation that Staff did not respond to requests for communication about resident in care in a timely manner. All staff (S1-S4) stated that they do not give out medical information to anyone other than those who are authorized by the resident to receive it: such as one who has a power of attorney or those that are responsible for the resident. S1 stated that R1s family member called and kept inquiring about R1s medical condition but S1 was told by R1 that R1 did not want R1s medical condition discussed with R1s family member. LPA interviewed R1-R9 about the allegation that Staff did not respond to requests for communication about resident in care in a timely manner. 8 of 9 residents denied the allegation and stated that they have not had any problems with staff communicating with their loved ones while in care.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20221012141025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SUNRISE AT PALOS VERDES
FACILITY NUMBER: 198602549
VISIT DATE: 03/19/2024
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 interviews, there is insufficient evidence to support the allegation that the Staff did not respond to requests for communication about resident in care in a timely manner. 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 Unsubstantiated.

Allegation # 3- Staff are not conducting a reappraisal on resident as necessary.

The details of the complaint alleged that the facility staff are not properly evaluating R1 because R1 is exhibiting signs of dementia and a reappraisal for R1 is warranted. On 03/19/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R9) regarding the allegation. R1 was not interviewed because R1 has since passed away. LPA attempted to contact the family member but was not able to with the current information on file. 4 of 4 staff denied the allegation that Staff are not conducting a reappraisal of resident as necessary. All staff (S1-S4) stated that when there is a change in a resident’s condition, they are re-evaluated, and their care plan is updated. S1 stated that R1 was reassessed but R1 declined further reappraisals. S1 stated that R1 did not want R1s family member to be involved in R1s care. LPA interviewed R1-R9 about the allegation that Staff are not conducting a reappraisal of resident as necessary. 8 of 9 residents denied the allegation and stated that they get regular physicals, and their medical plan is updated as needed.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not conducting a reappraisal on resident as necessary. 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 Unsubstantiated.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to Kelley Koul, Director.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3