198602882-10-22-2021-28-AS-LHIS-D4DLDE-20240416083942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602882
Report Date: 10/22/2021
Date Signed: 10/22/2021 12:59:40 PM

Unsubstantiated

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210622095000

FACILITY NAME:	SUNRISE ASSISTED LIVING OF CLAREMONT		FACILITY NUMBER:	198602882
ADMINISTRATOR:	MENSAH, ERIC		FACILITY TYPE:	740
ADDRESS:	2053 N TOWNE AVE		TELEPHONE:	(909) 398-4688
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	81	CENSUS: 57	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Roger Endert		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Residents sustained falls while in care
Facility staff did not isolate a contagious resident
Facility staff did not prevent residents from engaging in a physical altercation

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's) Jewel Baptiste and Linda Almaraz conducted a subsequent complaint visit to investigate the allegations listed above. LPA's were greeted by staff member Angelica Navarro and explained the reason for the visit. Later at about 9:58AM, Administrator Roger Endert arrived at the facility.

The investigation consisted of the following: On 6/23/21, LPA Almaraz conducted a health and safety check, interviewed former Administrator, Jennifer Serrano and requested copies of staff and resident rosters along with other pertinent documentation. On 9/29/21, LPA Almaraz interviewed Staff #1-3 and requested additional records for Residents #1-5. On 10/22/21, LPA's Baptiste and Almaraz interviewed Staff #4 and attempted to interview Staff #5-8 telephonicallly but were unsuccesful. LPA's obtained copies of the facility's progress notes on Resident #1 and testing records for Resident #5.

The investigation revealed the following: (Continued on an LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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 28-AS-20210622095000

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING OF CLAREMONT	FACILITY NUMBER: 198602882
	VISIT DATE: 10/22/2021

NARRATIVE

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In regards to allegation "Residents sustained falls while in care" it was alleged Resident #1 had an un witnessed fall at the facility and a staff member that reported the incident was disregarded. Interviews with staff members and records revealed the resident was a fall risk resident and was in memory care. Although the resident was a fall risk resident, the resident did not have a 1:1 caregiver assigned. According to records and interviews, the resident had a low bed and a fall mat in place and would receive frequent checks. Based on records reviewed the resident was found unresponsive in bed on 7/4/2020 and was sent to the hospital. On 9/9/2020, the resident was refusing to use the walker around 10:45AM and was later found laying supine on the floor of his room during a room check. The resident was assessed and assisted back into bed. On 9/21/2020, the resident was found on the floor in a sitting position next to the bed against the wall and was assessed by a med-care manager who assisted the resident into the wheelchair. On 10/21/2020, the resident was found on the floor next to the residents bed, a body check assessment was done and hospice was contacted due to 2 excoriations on the resident. On 10/23/2020, the resident was found again in a kneeling position next to the bed. They assessed the resident and noted no injuries and the resident denied pain. The residents vitals were also taken that day. On 10/24/2020, the resident was found laying in the floor mat at about 4:30PM. They conducted a body check, checked the residents vitals and was assisted back into bed. According to records the resident received a new hospice bed on 10/23/2020. After each fall the resident was assessed and was sent out the hospital when needed.

In regards to allegation "Facility staff did not isolate a contagious resident" it was alleged a resident was not quarantined upon move in and gave COVID-19 to another resident at the facility. Based on records reviewed and interviews conducted the facility only quarantines new admissions to the facility. Resident #5 was an assisted living resident at the facility and was moved into memory care after displaying memory issues. Resident #5 was moved into memory care on 1/14/21 and was tested prior to being moved in with Resident #4. Resident #5 was tested before on 1/12/21 and after on 1/16/21 and was negative for COVID-19. Resident #5 was tested as well on 1/12 and 1/17, and was negative for COVID-19. There is no evidence that shows Resident #5 gave Resident #4 COVID-19.

In regards to allegation "Facility staff did not prevent residents from engaging in a physical altercation" it was alleged 2 residents engaged in altercation that lead to a laceration on the left forearm of one of the residents. (Continued on an LIC9099C)

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210622095000

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING OF CLAREMONT	FACILITY NUMBER: 198602882
	VISIT DATE: 10/22/2021

NARRATIVE

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Based on records reviewed and interviews conducted, on 12/19/2019, Resident #2 was found on the floor of Resident #3's room with a laceration in the left forearm after Resident #3 was calling for help for Resident #2. Both are residents in memory care. No caregivers witnessed the incident. Later there was speculations that Resident #3 had cut Resident #2 with a soda can or frozen can because the resident had history of aggressive behavior. There was no blood found on Resident #3. There was no witnesses to the incident or evidence of an altercation happening and an object being used on Resident #2.

Based on LPA's interviews conducted, and records reviewed, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with the Administrator and a hardcopy was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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