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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602882
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:39:51 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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 Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210622095000
FACILITY NAME:SUNRISE ASSISTED LIVING OF CLAREMONTFACILITY NUMBER:
198602882
ADMINISTRATOR:MENSAH, ERICFACILITY TYPE:
740
ADDRESS:2053 N TOWNE AVETELEPHONE:
(909) 398-4688
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:81CENSUS: 45DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Lachaun Gill Business Office Director and Schamone Bard, Health Service Director. TIME COMPLETED:
01:49 PM
ALLEGATION(S):
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Questionable death
INVESTIGATION FINDINGS:
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Licensed Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to the facility to deliver findings on 2 allegations. LPA met with Lachaun Gill Buisness Office Director and Schamone Bard, Health Service Director and discussed the purpose of the visit.

The Department’s Investigative Branch (IB) conducted the investigation into the allegation above and the following are the findings.

Regarding allegation – Questionable Death – It is alleged that facility resident R1 was a high fall-risk and sustained multiple falls at the facility, but the facility failed to adequately meet R1’s needs, ultimately leading to a fall on 6/25/2020 that resulted in R1 neck fracture and death.

(continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 6
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SUNRISE ASSISTED LIVING OF CLAREMONT
FACILITY NUMBER: 198602882
VISIT DATE: 02/22/2024
NARRATIVE
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According to facility records and staff member statements, R1 sustained several falls at the facility and was at a high risk for falls because of increased weakness/confusion. To address this risk, facility Resident Care Coordinator Veronica Hermosillo repeatedly instructed Care Managers, the last documented instance of which was on 6/23/2020, to conduct more frequent status and incontinence checks for R1, since R1 continued getting out of bed, or attempting to, without calling for assistance. Kaiser Hospice Care Manager Nurse Alexander Santos also advised the facility on 6/25/2020 to conduct frequent checks. The facility does not document when room checks are done, but per facility Follow Up Question Reports, the last documented time a staff member assisted R1 with R1 incontinence needs was on 6/25/2020, prior to R1 being found on the floor at approximately 2330 hours, was at 2006 hours. This would suggest that R1’s briefs were not changed for nearly three and a half hours. Lead Care Managers Edward Umemoto and Dewi Sommer each told IB investigator that an initial safety check was done shortly after the start of their 2200 hours shift, but Sommer, who was responsible for R1 that night, told IB investigator that she usually did not conduct incontinence checks until 2330-2400 hours. Hermosillo told IB investigator that the facility concluded in its own investigation that Umemoto failed to check on R1 at the beginning of the overnight shift. Umemoto was counseled for failure to follow the instructions since he “failed to do resident rounds at the beginning of the shift as is the procedure.” In its corrective action plan, the facility instructed that “[Umemoto] will check all residents first thing at the beginning of the shift and throughout the shift to ensure all residents are safe and needs are met.” On 6/25/2020, R1 was found on the floor due to an unwitnesed fall. R1 had abrasion on head and R1 stated R1 hit his head. Facility did not call 911. Although the facility failed to call 911 right away, when the resident was finally admitted to the hospital the next day 06/26/2020, he had a chance to have a surgical intervention for his cervical fracture, however, the family chose to provide him comfort care only without further intervention, so the resident was extubated and then passed away shortly, the resident might live longer after the surgical intervention. There is insufficient evidence to substantiate this allegation, therefore it is UNSUBSTANTIATED
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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 Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210622095000

FACILITY NAME:SUNRISE ASSISTED LIVING OF CLAREMONTFACILITY NUMBER:
198602882
ADMINISTRATOR:MENSAH, ERICFACILITY TYPE:
740
ADDRESS:2053 N TOWNE AVETELEPHONE:
(909) 398-4688
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:81CENSUS: 45DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Lachaun Gill Business Office Director and Schamone Bard, Health Service DirectorTIME COMPLETED:
01:49 PM
ALLEGATION(S):
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Facility staff did not seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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The investigation by the Investigative branch (IB) revealed the following:

Regarding Allegation: Facility staff did not seek medical attention in a timely manner. Facility resident R1 did not receive the medical attention R1 required after sustaining a head injury because the facility initially called hospice instead of 911.
The investigation revealed:

Care Managers Umemoto and Sommer told IB investigator Jose Santana that they would have called 911 as a result of this head injury that R1 suffered had R1 not been on hospice because this is what they are trained to do for head injuries. Their understanding is that if a hospice resident sustains a fall, the facility is to notify hospice, and hospice would then make the determination on whether to call 911. Facility resident care coordinator Veronica Hermosillo told IB investigator Santana that the care managers should have called 911 for R1’s head injury in addition to hospice despite R1 being on hospice.
(continued on 9099C)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SUNRISE ASSISTED LIVING OF CLAREMONT
FACILITY NUMBER: 198602882
VISIT DATE: 02/22/2024
NARRATIVE
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 Per 22 CCR § 87469(c)(3), “Specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is directly related to the expected course of the resident's terminal illness, the facility may immediately notify the resident's hospice agency in lieu of calling emergency response (9-1-1). For emergencies not directly related to the expected course of the resident's terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” Per California Health and Safety Code §1569.73(c), facility staff must have received training from the hospice agency on the expected course of the resident’s illness and the symptoms of impending death to notify the hospice agency in lieu of 911. Because R1’s head injury and resulting neck pain were not a direct consequence of R1 illness and given that the facility called 911 for R1 when R1 sustained a head injury on 11/27/2019, prior to the start of R1 hospice care, it is a logical conclusion that the facility would otherwise have called 911 had R1 not been on hospice. R1 was not sent to the hospital until the next day on 06/26/2020, Facility Resident Care Director Kayleigh Barton acknowledged that she only recently became aware of 22 CCR § 87469(c)(3) but made the argument that R1’s fall and resulting fracture could be considered a direct result of R1 current illness. But Hermosillo conceded that the facility’s error was in not calling 911 once R1’s head injury was discovered. Care managers Edward Umemoto and Dewi Sommer informed IB investigator Santana that they assessed R1 for injury by asking R1 to move R1’s limbs and if R1 was in pain. Umemoto and Sommer acknowledged knowing that R1 had hit R1’s head, and that if R1 had expressed pain, they would not have moved R1 from the floor. Sommer told IB investigator that the facility did not provide specific training on how to assess residents post fall.


(CONTINUE ON 9099C)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SUNRISE ASSISTED LIVING OF CLAREMONT
FACILITY NUMBER: 198602882
VISIT DATE: 02/22/2024
NARRATIVE
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R1 was moved from the floor after a head injury by facility caregivers without proper assessment. On 06/25/2020 at 23:30, it was noted that resident was found on floor next to his bed and stated R1 hit his head on the wall. 2 team members observed R1 and noted abrasion to right arm, left knee, forehead and top of head. R1 was assisted back to bed and call to hospice and family was made. No call to 911 was made at this time. R1 was not transported to hospital until the next day 6/26/2020.

The allegation that the facility failed to obtain adequate medical attention by calling 911 right after R1 suffered fall and sustained serious injuries is SUBSTANTIATED.


Based on Investigative branch investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, is cited on the attached LIC 9099D.

LPA conducted an exit interview with the Lachaun Gill, Business Office Director and provided a copy of report, 809D and appeal rights.

The facility has been informed that Immediate $500 civil penalty will be issued based on health and safety code 1569.49

“The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).“

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING OF CLAREMONT
FACILITY NUMBER: 198602882
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/29/2024
Section Cited
CCR
87469(c)(3)
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87469
Advanced Directives and Requests Regarding Resuscitative Measures
(c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following.
(3) Specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is directly related to the expected course of the resident’s terminal illness, the facility may immediately notify the resident’s hospice agency in lieu of calling emergency response (9-1-1). For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).

This requirement is not met as evidenced by:
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Facility will train all staff on when to call 911 for hospice residents and send copy of agenda with signature of all staff in attendance.

$500 immediate civil penalty issued.
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Facility staff failed to initially call 911 on a timely manner per facility protocol for signs of head injury when resident fell and injured head, and instead called hospice. Staff stated that they were not aware that they were required to call 911 when a resident is on hospice.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6