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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602882
Report Date: 03/22/2022
Date Signed: 04/21/2022 03:10:22 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
04/12/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210412110433
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: 59DATE:
03/22/2022
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Roger Endert- Executive Director TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Questionable death.
Staff did not obtain medical treatment to resident in a timely manner.
Resident fell while in care.
Resident's needs are not being met.
Staff did not safeguard resident's belongings.
INVESTIGATION FINDINGS:
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*** THIS REPORT SUPERSEDES THE REPORT GENERATED ON 03/22/22 ***
This report supersedes the report dated 03/22/22 for clarifying the circumstances for the allegation#1. Although this Report supersedes the previous report the complaint investigation findings remain the same: Unsubstantiated

Licensing Program Analyst (LPA) Christine Wong conducted a subsequent visit to investigate the above
allegations. LPA met with Receptionist Caroline Flores Herenandez and explained the reason of the visit. Shortly after, the Resident Care Director Kayleigh Barton arrived and assisted with the visit.

The investigation consisted of following: On 04/13/2021, LPA Almaraz conducted an initial 10 days visit and conducted a healthy and safety check for the facility and obtained copies of staff and resident rosters.
(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
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 6
Control Number 28-AS-20210412110433
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: 03/22/2022
NARRATIVE
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In addition, on 04/13/21, the Allegations #1 through 3 of the complaint was accepted by Centralized Complaint and Information Bureau (CCIB) Unit for full investigation and assigned to investigator Jose Santana. IB investigator Santana conducted and complete investigation which includes interviews with the family members, ten (10) facility staff, Claremont Police, four (4) hospice staff and the physician for Resident#1 (R1). IB Investigator Santana also obtained documents include Hospital Medical Record, Police report, 911 call log and hospice medical record. On 09/29/21, LPA Almaraz conducted an additional visit to interview Staff#1-#3. On today’s visit, LPA Wong interviewed additional six (6) residents (R2-R7) and five (5) staff (S1-S5) and obtained copy of current resident and staff roster.

The investigation revealed of the following: Allegation#1 “Questionable Death”, IB Investigator Santana reported Resident#1 (R1) was admitted to hospice care on 11/20/20 due to heart failure and on 11/27/20, R1 exhibited several symptoms which are expected for R1’s medical condition. The hospice agency and R1’s primary care physician already advised R1's symptoms prior to his death were consistent with the expected course of his terminal illness. The facility would not have been required to call 911 in response to R1’s symptoms because they were in line with the expected course of R1's terminal illness. The proper course of action would have been to notify hospice, which is exactly what facility lead care manager did. A blood sugar level of 400mg/dL which is high but not considered a diabetic emergency. Per the hospice agency and R1's primary care physician, likely did not contribute to R1's death, and it was most likely a heart attack that caused it..Therefore the allegation for R1’s death was questionable in nature is therefore UNSUBSTANTIATED.

Allegation#2 “Staff did not obtain medical treatment to resident in a timely manner.” IB investigator Santana reported that the facility record indicate that the facility lead manager called the hospice agency for R1’s change of condition on 11/27/2020. The hospice record indicated that the hospice agency staff provided in service training to facility nurse over the phone on 11/20/20 and informed the facility nurse that R1 would exhibit some course of signs or symptoms for the terminal phase. Due to the several symptoms that R1 exhibited which was related to the expected of R1's medical condition. The facility nurse did as instructed and called hospice agency in lieu of 911.

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20210412110433
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: 03/22/2022
NARRATIVE
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Allegation#3 “Resident fell while in care. “ IB investigator Santana reported on 11/18/20, sometime between 11:29pm to 11:46pm, the facility staff found R1 lying on the floor next to his bed and the facility called 911 at 11:46pm, and hospital concluded R1 had swelling of anterior scalp soft tissue without acute intracranial hemorrhage as well as abrasion to forehead and nose bridge. Prior R1's admission to the facility, the facility already noted on the Preplacement Appraisal, R1 was non-ambulatory and was not able to walk without assistance and need help with transferring. The facility was also aware R1 had a fall prior to admission which was indicated on R1's Individual Service Plan and facility also accommodated R1's fall risk and would provide 2-4 more room checks per shift, to the standard 3-4 per shift. And according to the facility records, the facility staff did contact R1 prior to the fall incident at 10:59pm for checking his glucose level. In addition, there's no written documents indicated that R1's family made any request for any fall precaution even the facility agreed to put a fall mat in place, and it's an un-witnessed fall.

Allegation#4 "Resident's needs are not being met." LPA interviewed six (6) residents and five (5) out of six (6) residents reported the facility is able to meet their needs most of the time. They are happy to live there and they have good staff working in the facility. LPA interviewed the staff and staff reported although its challenging, they are trying their best to meet the residents needs. And they do not receive any complaints from residents about their needs are not being met.

Allegation#5 "Staff did not safeguard resident's belongings." LPA interviewed six (6) residents and five (5) out of six (6) residents reported they never lost anything or missed any personal belongings in the facility. They all feel safe living in the facility. LPA interviewed staff and reported sometimes residents may forget where they put things are and staff are able to locate their personal belongings in their rooms. In regard to R1's belongings, staff reported it was mistakenly taken by other resident family members and donated at Goodwill. And staff was able to contact Goodwill and collect back most of R1's belongings.

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 Executive Director and copy of the report and an appeal right was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
04/12/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210412110433

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: 59DATE:
03/22/2022
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Roger Endert- Executive Director TIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Inadequate staffing
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted a subsequent visit to investigate the above allegations. LPA met with Receptionist Caroline Flores Herenandez and explained the reason of the visit. Shortly after, the Resident Care Director Kayleigh Barton arrived and assisted with the visit.

The investigation consisted of following: On 04/13/2021, LPA Almaraz conducted an initial 10 days visit and conducted a healthy and safety check for the facility and obtained copies of staff and resident rosters. On 09/29/21, LPA Almaraz conducted an additional visit to interview Staff#1-#3. On today’s visit, LPA Wong interview additional six (6) residents (R2-R7) and five (5) and obtained copy of current resident and staff roster.

The investigaton revelaed of the following: Allegation "Inadequate Staffing." LPA interviewed six residents, six (6) out of six (6) residents reported that the facility has an inadequate staffing.
(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20210412110433
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: 03/22/2022
NARRATIVE
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The residents reported It has been an ongoing issues especially during the weekend. Residents reported sometimes they may have to get dress or showering by themselves due to staff was not able to come and help them. Also they may have to wait for half an hour to an hour for staff to take their order at the dining room. LPA also interviewed five (5) staff and four (4) out of five (5) staff reported the facility has an inadequate staffing. Staff reported especially the caregiver department. The staff are always rushed. Staff reported they only have three (3) caregivers during the weekend. They have to assist the residents with changing, grooming, feeding ..etc and they also have to transferring residents from dining area back to their rooms. Although the facility did implement staffing agency came in and helped out but sometimes the agency staff would just stand there and do nothing. They are not very helpful. Staff also reported resident would call and ask why staff are not bringing their meals or why staff take so long to take them to the bathroom.

Based on LPA interviews conducted with facility staff and residents and 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.

Exit interview held. Copies of report and appeal rights were provided to Executive Director
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 28-AS-20210412110433
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements-General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The requirement is not met as evidenced by :
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The administrator will provide a plan for LPA about how to correct the issues of inadequate staffing and Send the plan to LPA by POC due date.
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LPA's interview with faciltiy staff and residents, 6/6 residents and 5/6 staff reported the facility has an inadequate staffing. Staff was not able to help residents with some of the needs including getting dress or shower or they have to wait so long at the dining for staff take order
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6