198603283-10-5-2023-28-AS-RORN-CY2NQQ-20231129094020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603283
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:01:46 PM

Substantiated

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
10/02/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231002085356

FACILITY NAME:	VICTOR SUNSHINE RESIDENTIAL CARE		FACILITY NUMBER:	198603283
ADMINISTRATOR:	MORA, VICTOR OLIVER R		FACILITY TYPE:	735
ADDRESS:	1410 S. RIDLEY AVE.		TELEPHONE:	(626) 346-3498
CITY:	HACIENDA HEIGHTS	STATE: CA	ZIP CODE:	91745
CAPACITY:	4	CENSUS: 3	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Victor Mora - Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not accord resident privacy.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bennette Pena conducted the initial 10-day unannounced complaint visit to investigate the above allegation. LPA met with the Administrator, Victor Mora and discussed the purpose of today's visit.

The investigation consisted of the following: LPA obtained copies of Client & Staff Rosters, House Rules/House Values, Letter written by Administrator on behalf of Client #1 (C1) (dated 9/29/2023), C1 files such as; Admission Agreement, Client's Rights, Physician's notes (10/02/2023), Identification and Emergency Information, Appraisal/Needs and Services Plan (10/05/2023) and IPP (12/19/2022). LPA interviewed Staff #1 (S1) - Staff #2 (S2), Client #2 (C2) and telephonically interviewed Staff #3 (S3) and Client #1 (C1). LPA was unsuccessful in interviewing Client #3 (C3) as he is non verbal.LPA called Staff #4 (S4), but no answer and voice mail has not been set up yet. LPA left a voice mail message to SC requesting a call back.

*****CONTINUED ON LIC9099-C*****

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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 3

Control Number 28-AS-20231002085356

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: VICTOR SUNSHINE RESIDENTIAL CARE	FACILITY NUMBER: 198603283
	VISIT DATE: 10/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following:

In regards to the allegation: "Staff did not accord resident privacy", it is alleged that it was discovered that C1 had 2 air tags in his front right pocket and staff had given those to C1 to keep with him. S1 corroborated the allegation and stated that he provided the air tags to C1 for his safety and to track and monitor him to make sure that the Administrator know where C1 is at all times. S1 stated that it was C1 who likes to bring the air tags because it was recommended to C1 by the law enforcement months ago, according to C1. However, there was no evidence provided to LPA about this communication. S1 also stated that he typed up a letter on behalf of C1 to inform the day program that no one is forcing him to carry those items. Interview with S2 indicated that she does not know what an air tag is for and no idea what those are for. Interview with C1 indicated that he does not know what air tags are for and why he has those in his pocket. C1 also stated that he did not write a letter regarding the air tags. Interview with C2 revealed that he is aware that C1 carries air tags and know that those are for tracking. LPA reviewed the signed letter written by the Administrator on behalf of C1 indicating that no one is forcing C1 to carry those items. However, C1 denied writing the letter and indicated that he has no knowledge of the letter. LPA did not observe other supporting documentation regarding C1 carrying trackers/air tags. Interview with Regional Center indicated that they are investigation the situation.

Based on LPA’s interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to Victor Mora, Administrator along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20231002085356

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: VICTOR SUNSHINE RESIDENTIAL CARE	FACILITY NUMBER: 198603283
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/11/2023 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072 Personal Rights..(a) .. each client shall have personal rights which include..(1) To be accorded dignity in his/her personal relationships with staff and other persons. This deficiency was evidenced by the following:	1 2 3 4 5 6 7	Administrator will ensure each client to be accorded dignity in his/her personal relationships with staff and other persons. Administrator will submit an effective plan on how to prevent unauthorized tracking and avoid leading to client's privacy invasion to CCL/LPA by POC due date.
	8 9 10 11 12 13 14	Client #1 was carrying (2) air tags to track and monitor his whereabouts which poses a potential health, safety or personal rights 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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3