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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603283
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:07:23 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
06/29/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230629083735
FACILITY NAME:VICTOR SUNSHINE RESIDENTIAL CAREFACILITY NUMBER:
198603283
ADMINISTRATOR:MORA, VICTOR OLIVER RFACILITY TYPE:
735
ADDRESS:1410 S. RIDLEY AVE.TELEPHONE:
(626) 346-3498
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:4CENSUS: 3DATE:
07/06/2023
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Victor MoraTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not ensure that resident's medications were refilled.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 07/06/23 regarding the above allegations. LPA Ramirez was met by Administrator Victor Mora and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #(S1)1 interview, Copies of Client#1 (C1): Face sheet, Physician’s Order dated 1/1/23 through 7/1/23, Agreements and Consent for Medical Treatment, Admission Agreement, Individual Program Plan (IPP) dated 4/20/2022, IPP Quarterly Progress Report meeting date of 11/17/21 and physical plant tour.

SEE 9099-C for continuance.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
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 2
Control Number 28-AS-20230629083735
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: 07/06/2023
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff did not ensure that resident’s medications were refilled- It is alleged that facility staff failed to get C1’s medication refilled since February of 2023. LPA reviewed and obtained copies of Physician’s Orders dating back from 1/1/23 through 7/1/23 and list several different prescription medications LPA Ramirez reviewed Medication Administration Record (MAR) through the months of 1/1/23 through 7/1/23. LPA Ramirez did not observe any discrepancies in MAR for January 2023 through June 2023 or lack of record keeping that would indicate facility staff did not order refill medications according to the physician’s order. Staff interviewed deny this allegation. 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.

Exit interview was conducted and a copy of this report was provided to Administrator Mora.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2