198602882-10-20-2021-28-AS-WSHO-C9Q26P-20211214160728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602882
Report Date: 10/19/2021
Date Signed: 10/20/2021 08:14:43 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 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
09/24/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210924115924

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: 56	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator Roger Endert		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff is withholding resident's personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted a subsequent complaint visit to deliver the findings for the allegation listed above. LPA met with Administrator Roger Endert and discussed the reason for todays visit.

The investigation consisted of the following: Initial visit was conducted on 9/29/2021 and LPA requested staff and resident roster, interviewed Executive Director, Resident #1 and Attorney for Resident #1 telephonically. LPA also requested Resident #1's Emergency ID page, and Physician's Report. POA documentation given to LPA at visit.

At today's visit 10/19/2021 at 1:10 P.M. Administrator Roger Endert was interviewed.
In regards to the allegation Facility staff is withholding resident's personal belongings, based on information gathered and interviews conducted with staff, resident # 1, attorney for resident # 1 and Power of Attorney Documentation it was revealed that there was a Revocation of Power of Attorney dated 8/12/2021 and signed 7/28/2021 by

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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-20210924115924

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: 10/19/2021

NARRATIVE

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Resident # 1 which resulted in family member no longer being allowed to make decisions on behalf of Resident # 1.
Physician from Scripps College on visit with Resident # 1 determined that she retains capacity to revoke POA.
Interview with Resident # 1 on 9/29/2021 who stated that she had never wanted to leave the facility and never wanted her personal belongings removed.
Stated that she liked the facility and had no idea family member had planned to try and remove her.
Said that she is responsible and competent to make her own decisions and even took a competency test with a physician who confirmed that.
She said family member was no longer Power of Attorney and that she signed a revocation of Power of Attorney and she can make her own decisions.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with the Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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