198602881-6-17-2021-11-AS-MCAA-C5XUDP-20210816152951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602881
Report Date: 06/17/2021
Date Signed: 06/17/2021 04:09:34 PM

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
04/16/2021 and conducted by Evaluator Jennifer Jones

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210416095057

FACILITY NAME:	SUNRISE VILLA CULVER CITY		FACILITY NUMBER:	198602881
ADMINISTRATOR:	EDALATI, SAHAR		FACILITY TYPE:	740
ADDRESS:	4061 GRAND VIEW BLVD		TELEPHONE:	(310) 390-0565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	150	CENSUS: 71	DATE:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Brandon Collins		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Resident sustained injuries from multiple falls while in care
Staff did not properly report incidents involving a resident
Staff did not properly assist a resident with dementia

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) initiated a complaint investigation and delivered findings for the allegations listed above. LPA met with Executive Director, Brandon Collins and explained the reason for the visit.

On 04/22/21, LPA conducted a facetime with the Executive Director, Brandon Collins and Resident Care Director, Lisa Cherqaoui and discussed the allegations. During the call LPA requested the following documents: resident and staff roster with staff phone numbers, resident 1's admission agreement, appraisals, physician report, medical records, internal notes, care plan and hospice records.

On 06/17/21, LPA met with Executive Director, Brandon Collins and delivered findings.

The allegation revealed the following: For allegation (Resident sustained injuries from multiple falls while in care) It is being alleged that a resident in care sustained multiple falls which one fall resulted in resident going into the hospital. . LPA Jones interviewed Executive Director, Brandon Collins about the allegation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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-20210416095057

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: SUNRISE VILLA CULVER CITY	FACILITY NUMBER: 198602881
	VISIT DATE: 06/17/2021

NARRATIVE

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According to Executive Director, Brandon Collins, R1 did suffer from multiple falls while in care and the team put a plan together to check the resident more frequently. LPA interviewed Resident Care Director, Lisa Cherqaoui who stated that R1 did suffer from multiple falls and a head injury. L. Cherqaoui stated that R1 was taken to the hospital after the incident and was treated for the injury. L. Cherqaoui stated that R1 fell more than once at the facility and paramedics came out to evaluate her but did not take resident in. S3 stated that resident fell often. S3 stated that resident suffered from dementia and wouldn’t listen to orders. S4 and S5 stated that they did not assist R1. S4 and S5 stated that if a resident is a fall risk then they will check on the resident more often. Usually every 30 minutes. Residents 2-8 stated that they have not experienced any falls and they have not witnessed any other residents fall while in care.

For allegation: (Staff did not properly report incidents involving a resident) It is being alleged that staff did not report resident falls. Executive Director, Brandon Collins revealed during his interview that he was not aware that resident falls needed to be reported to licensing. ED Collins stated that he did not send Special Incident Reports (SIRs) because he thought that a fall wasn’t an unusual incident. ED Collins stated that some residents are fall risk and falls will sometimes happen. ED Collins stated that he contacted licensing to get clarification and was told he should have reported it. Resident Care Director, Lisa Cherqaoui stated that R1’s fall that resulted in R1 going into the hospital happened before they received clarifications to report to licensing. Staff 3- 5 stated that they are not in charge of reporting to licensing. S3- S5 stated that they report incidents to management.

For allegation: (Staff did not properly assist a resident with dementia) It is being alleged that staff did not properly assist resident with dementia from falls. Executive Director and Resident Care Director, Lisa Cherqaoui stated that due to R1 having multiple falls, the facility put a plan in place to check on R1 more frequently. Staff 3 revealed during her interview that due to resident’s dementia diagnosis, R1 was stubborn and would fight staff. Staff 3 stated that they needed 3 caregivers to assist sometimes with hospice due to resident being difficult. Staff 4 and Staff 5 stated that they did not assist R1. LPA reviewed R1’s file and did not observe reappraisal

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210416095057

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: SUNRISE VILLA CULVER CITY	FACILITY NUMBER: 198602881
	VISIT DATE: 06/17/2021

NARRATIVE

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conducted on R1 indicating that resident conditioning was declining and the facility was unable to meet the needs of the resident.

Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations 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 is being furnished

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20210416095057

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: SUNRISE VILLA CULVER CITY	FACILITY NUMBER: 198602881
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/24/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or	1 2 3 4 5 6 7	The administrator will send a plan to licensing indicating on how they will observe residents moving forward regarding change in condition. The administrator will send it by pOC due date
	8 9 10 11 12 13 14	deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidence by: The facility failed to access resident due to multiple falls.	8 9 10 11 12 13 14
Type B 06/24/2021 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following. 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. This report was not met as evidence by:	1 2 3 4 5 6 7	The administrator contacted licensing to receive clarification regarding reporting falls on 02/2021 and since incident the administrator as reported all falls. POC cleared during visit.
	8 9 10 11 12 13 14	The facility failed to submit incident reports to licensing of R1's multiple falls and one fall which resulted in resident going into the hospital.	8 9 10 11 12 13 14

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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

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