198602887-11-3-2021-11-AS-JHAD-C8T3BR-20211115170643

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602887
Report Date: 11/02/2021
Date Signed: 11/03/2021 09:31:39 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
12/09/2020 and conducted by Evaluator Martessa Brown

COMPLAINT CONTROL NUMBER: 11-AS-20201209123820

FACILITY NAME:	SUNRISE ASSISTED LIVING OF HERMOSA BEACH		FACILITY NUMBER:	198602887
ADMINISTRATOR:	MORRIS, TRAVIS		FACILITY TYPE:	740
ADDRESS:	1837 PACIFIC COAST HWY		TELEPHONE:	(310) 937-0959
CITY:	HERMOSA BEACH	STATE: CA	ZIP CODE:	90254
CAPACITY:	142	CENSUS: 80	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	11:23 AM
MET WITH:	Janelle Odishoo and Ami Mehta		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility plumbing is in disrepair.

INVESTIGATION FINDINGS:

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On 11/2/21 Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Janelle Odishoo, the facility administrator and Ami Mehta-Resident Care Direcor and the purpose of the visit was explained.

The investigation consisted of the following: On 12/20/20 LPA Brown toured the physical plant and laundry rooms with Travis Morris-Administrator. LPA conducted interview with Mr. Morris and requested/obtained copies resident’s and staff roster, resident R1’s file: Physician’s Report, Appraisal’s/Needs and Service Report, Special Diet Restrictions, Emergency Identification and Admission Agreements. Plumbing invoices for the month of December 2020, Letters sent to family/residence regarding the allegation, Theft & Loss Policy, copy of receipts reimbursement to residents, laundry room schedule/procedure and incident reports related to the above allegation.

LIC9099-C is on the next page

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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-20201209123820

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 ASSISTED LIVING OF HERMOSA BEACH	FACILITY NUMBER: 198602887
	VISIT DATE: 11/02/2021

NARRATIVE

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The investigation consisted of the following:

Regarding allegation: Facility plumbing is in disrepair

On 12/20/20 LPA conducted interview with Travis Morris, Administrator. He stated there was problems with the hot water that effected 2 hallways on 12/4/20. He stated the plumbing company came out on these dates 12/6/20-12/9/20 to fix the value. He stated since 12/10/20 there hasn’t been any problems. He stated notices was sent to family on 12/8/20. He also stated did not submit an incident report to CCLD. He stated residents that were not able to shower were offered to take one in other empty rooms. On 11/2/21 LPA conducted interviewed residents # 1-8, 3 out 8 residents stated there was a problem with not having hot water for a couple of days and only 1 stated received a notice. LPA conducted interviews on 11/2/21 with Staff #1-5. 1 out of 5 staff stated the hot water was turned off for 2 days and was notified by maintenance and they will notify residents.

Based on LPAs observations, document and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 Chapter 8.

Exit Interview Conducted, appeal rights given to Administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 11-AS-20201209123820

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 ASSISTED LIVING OF HERMOSA BEACH	FACILITY NUMBER: 198602887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/09/2021 Section Cited CCR 8703(a)	1 2 3 4 5 6 7	Maintenace & Operation 8703 (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will submit to LPA an incident report and a plan on how they will notify CCLD by Poc date 11/9/21
	8 9 10 11 12 13 14	Based on observations and interviews conducted, Residents did not have hot water for a substantial amount of time and were informed they would have to use other bathrooms to shower. CCLD was not notified of the incident. This is a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

Page: 4 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
12/09/2020 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201209123820

FACILITY NAME:	SUNRISE ASSISTED LIVING OF HERMOSA BEACH		FACILITY NUMBER:	198602887
ADMINISTRATOR:	MORRIS, TRAVIS		FACILITY TYPE:	740
ADDRESS:	1837 PACIFIC COAST HWY		TELEPHONE:	(310) 937-0959
CITY:	HERMOSA BEACH	STATE: CA	ZIP CODE:	90254
CAPACITY:	142	CENSUS: 80	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	11:23 AM
MET WITH:	Janelle Odishoo and Ami mehta		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff mishandled resident's personal belongings

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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-20201209123820

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 ASSISTED LIVING OF HERMOSA BEACH	FACILITY NUMBER: 198602887
	VISIT DATE: 11/02/2021

NARRATIVE

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On 12/20/20 LPA conducted interview with Travis Morris, Administrator. He stated there was 1 residents socks that were missing, but they were replaced. He also mentioned if they were unable to replace they will give the residents a credit. He stated they also have an itemized list of residents clothing. On 11/2/21 LPA conducted interviews with resident #1-8, 1 out of 8 residents stated they had missing underwear and socks. LPA conducted interviews with staff #1-5, staff stated they have an calendar and clothes are cleaned on night shift. They stated on some occasions residents’ clothes have been misplaced if they do not have labels. Staff stated they will keep clothes in the laundry room until they are claimed.

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 and a copy of the report was given.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5