198602881-8-11-2021-11-AS-MVAO-C5YQW3-20210817123115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602881
Report Date: 08/06/2021
Date Signed: 08/11/2021 08:19:41 AM

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
06/03/2020 and conducted by Evaluator Susan Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200603115845

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: 73	DATE:	08/06/2021
		UNANNOUNCED	TIME BEGAN:	01:19 PM
MET WITH:	Brandon Collins		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident moved by staff to another apartment without notifying responsible party.

INVESTIGATION FINDINGS:

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On 8/6/21, Licensing Program Analyst (LPA)/ Susan Campos initiated a subsequent complaint investigation visit to deliver findings for the allegation listed above. LPA was allowed entry into the facility by Brandon Collins, Administrator. Mr. Collins has been an administrator for the facility since 10/2/2020, and also was not affiliated with the facilty until 10/2/2020. LPA explained to Mr.Collins, the purpose of today’s visit. The investigation consisted of the following: LPA conducted telephone interview with (6) staff members, and (6) teleconference resident interviews. In addition, on 6/8/2020, LPA conducted a telephone/video inspection, of the facilities’ physical plant and food supply for health and safety. Areas covered, in the teleconference, included: common areas, front door and reception area, dining room, kitchen, and food supply. Also, LPA reviewed the following documents: staff roster, client roster, admission agreement, COVID-19 PPE staff policy, COVID-19 staff and resident information letters, and R1’s case notes/ correspondence, R1’s assessment record, R1’s physician reports, and R1’s admission agreement.

Report Continued on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

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-20200603115845

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: 08/06/2021

NARRATIVE

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Allegation:

Resident moved by staff to another apartment without notifying responsible party.

The investigation revealed, per LPA interviews, with staff members, and residents, that the Sunrise Villa Culver City facility moved a resident, to another apartment, without notifying responsible party. LPA conducted interviews with staff members and staff at the Sunrise Villa Culver City facility, and reviewed record documents pertaining to the complaint. On 6/4/20, R1’s Power of Attorney (POA), informed LPA, that POA was not informed by Sunrise Villa Culver City staff member S1, that R1 was to be transferred, on 4/16/20, from current room, to a room at the Sunrise Villa Culver City - Terrace Club building. S1, informed LPA, that S1 contacted R1’s POA, per text message and telephone call, and stated that informed POA that R1 was reassessed by facility staff, and determined that R1 needed higher level of care, and therefore was recommended to transfer to the Sunrise Villa Culver City – Terrace Club. S1 states communicated to R1’s POA, per text message and telephone call, that LPA reviewed admission agreement “ Addendum XI – Memory Care Disclosure Statement – Memory Care Consent form “ signed by R1’s POA on 9/2/18. States on Page 2, Paragraph 2, that “A resident shall not be admitted or transferred to a secured neighborhood environment unless legal authority for admitting the resident has been established by guardianship, court order, medical durable power of attorney, health care proxy or other means allowed by State law”. S1 did not provide LPA with signed documentation, from POA, providing approval for the transfer of R1 from the assisted living service program to the memory care program. Nor was there documentation of a meeting or virtual teleconference, that confirms a discussion took place by the POA and S1 to discuss the reappraisal of R1. And further, no confirmation that a reappraisal conference took place to confirm the medical status or care needs for R1 and, furthermore no written explanation for the transfer of R1 to the Terrace Club.

Based on LPAs observations and interviews which were conducted record review, 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.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200603115845

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: 08/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/20/2021 Section Cited HSC 87463(c)	1 2 3 4 5 6 7	87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide LPA with procedural documents, for the transfer of residents from assisted living to memory care. The documents will be faxed to LPA(323)981-1781, by 8/20/21. POC Due Date: 8/20/21
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee failed to provide LPA documentation of a meeting, or other approval document, for the transfer of R1, to the Sunrise Villa Culver City Terrace Club, which posed a potential health 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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC9099 (FAS) - (06/04)

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