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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602881
Report Date: 03/18/2022
Date Signed: 03/21/2022 08:57:51 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
12/20/2021 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20211220142239
FACILITY NAME:SUNRISE VILLA CULVER CITYFACILITY NUMBER:
198602881
ADMINISTRATOR:COLLINS, BRANDONFACILITY TYPE:
740
ADDRESS:4061 GRAND VIEW BLVDTELEPHONE:
(310) 390-0565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:150CENSUS: 74DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Safoora AhmedTIME COMPLETED:
05:28 PM
ALLEGATION(S):
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Resident sustained unexplained injury while in care.
Facility did not provide transportation for resident(s) to appointment.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. LPA met with Executive Director Safoora Ahmed and explained the purpose of the visit.

The investigation consisted of the following: On 12/23/2021 Licensing Program Analysts (LPAs) Ulysses Coronel and Ngozi Nwaokoro conducted a tour of the facility, interviewed 5 staff, 1 witness and 5 residents and requested copies of staff and resident records. On 03/18/2022 LPA interviewed administrator Safoora Ahmed, 4 staff, 1 witness and 3 residents and conducted record reviews.

The investigation revealed the following: Regarding the allegation “Resident sustained unexplained injury while in care.” It is alleged that R1 sustained an unexplained injury while in care. On 12/23/2021 LPA conducted record reviews and did not observe an incident report regarding R1’s injury. On 12/23/2021 S1 stated that “T1 was on duty during the R1’s incident, T1 no longer works here.” W1 stated “I saw R1 with a big bump on their head while in bed, staff were not able to tell how it happened.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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 5
Control Number 11-AS-20211220142239
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: 03/18/2022
NARRATIVE
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On 03/18/2022 S6 stated “R1 needs a 2 person assist and is known to be a fighter.” On 03/18/2022 record reviews of R1’s Individualized Service Plan indicate that R1 needs 2-person assist during toileting and repositioning. The caregiver schedule indicates that there was only 1 agency staff present during the time of R1’s incident. Regarding the allegation” “Resident sustained unexplained injury while in care.” Based on interviews which were conducted and the records that were 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.

Regarding the allegation: “Facility did not provide transportation for resident(s) to appointment.” It is alleged that the facility was not able to provide transportation for R1 a wheelchair bound resident which made them miss a medical appointment. On 12/23/2021 S1 stated that “The facility bus needed repairs and the driver who had license to operate the facility bus left since August of this year. No other staff had permission to drive the bus on their driver’s license.” On 03/18/2022 the administrator stated that “We are still hiring for another driver.” Regarding the allegation” Facility did not provide transportation for resident(s) to appointment.” Based on interviews which were conducted and the records that were 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.

An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20211220142239
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: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited
CCR
87705(c)(4)
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Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:There is an adequate number of direct care staff to support each resident’s ...health care needs as identified in his/her current appraisal.This requirement was not met as evidenced by:
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The administrator will create a plan to ensure that there is adequate number of direct care staff available to residents. Proof of correction will be submitted via email by POC due date.
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Based on interviews and record reviews the licensee failed to ensure that There is an adequate number of direct care staff to support resident’s health care needs, on 10/03/21 there was only 1 staff available to provide care for R1 who needed 2 person assits, which poses a potential health and safety risk to residents in care.
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Type B
03/18/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In ...services. This requirement was not met as evidenced by:
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The administrator will create a plan to ensure that there is suficient number of staff to provide transportation to residents . Proof of correction will be submitted via email by POC due date.
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Based on interviews and record reviews the licensee failed to ensure that the transportation personnel are sufficient in numbers. The facility does not have a driver to operate the wheelchair access bus which poses a potential risk to residents in care.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
12/20/2021 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20211220142239

FACILITY NAME:SUNRISE VILLA CULVER CITYFACILITY NUMBER:
198602881
ADMINISTRATOR:COLLINS, BRANDONFACILITY TYPE:
740
ADDRESS:4061 GRAND VIEW BLVDTELEPHONE:
(310) 390-0565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:150CENSUS: 74DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Safoora AhmedTIME COMPLETED:
05:28 PM
ALLEGATION(S):
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Staff not notify resident’s authorized representative of incident involving resident.
Staff left resident in soiled clothing for extended period of time
Resident’s linens were soiled.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. LPA met with Executive Director Safoora Ahmed and explained the purpose of the visit.

The investigation consisted of the following: On 12/23/2021 Licensing Program Analysts (LPAs) Ulysses Coronel and Ngozi Nwaokoro conducted a tour of the facility, interviewed 5 staff, 1 witness and 5 residents and requested copies of staff and resident records. On 03/18/2022 LPA interviewed administrator Safoora Ahmed, 4 staff, 1 witness and 3 residents and conducted record reviews.

Regarding the allegation: “Staff not notify resident’s authorized representative of incident involving resident.” On 12/23/2021 W1 “I saw R1 in bed with a big bump on her head. I sat R1 on the wheelchair then I immediately notified the care coordinator. The Memory Care Director came in and called R1’s family and Primary Care Physician. S1 stated that “I was told about the incident by S2 the next day at 8:30am, R1’s family was already aware at the time.”
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20211220142239
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: 03/18/2022
NARRATIVE
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On 03/18/2022 S7 stated “When the staff who witnessed incidents like falls immediately reports the incident to either a med tech or any of the supervisors, then it is the med techs or supervisors who immediately contacts the authorized representative. Regarding the allegation: “Staff not notify resident’s authorized representative of incident involving resident.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation that: “Staff left resident in soiled clothing for extended period of time.” On 12/23/2021 W1 stated “It was actually staff who told me that R1’s clothes were wet while they were assessing R1 for injuries, I would sometimes see R1’s clothes wet in urine when I arrive.” On 03/18/2022 staff S3 stated “Some residents are heavy wetter’s. S4 stated “We check on residents often and change them as needed.” Regarding the allegation that: “Staff left resident in soiled clothing for extended period of time.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation that: “Resident’s linens were soiled..” On 12/23/2021 W1 stated “I never observed Estelles clothes soiled with feces.” On 03/18/2022 staff. S4 stated “We check on residents often and wash the linens daily.” Regarding the allegation that: “Resident’s linens were soiled.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5