198603294-4-5-2023-11-AS-MVAO-CSBTW7-20230530150505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603294
Report Date: 04/05/2023
Date Signed: 04/05/2023 04:52:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
03/02/2023 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230302152205

FACILITY NAME:	SUNSHINE ASSISTED LIVING		FACILITY NUMBER:	198603294
ADMINISTRATOR:	MARY MONTIANO		FACILITY TYPE:	735
ADDRESS:	3141 EUCLID AVE		TELEPHONE:	(310) 638-3847
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	68	CENSUS: 68	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	12:09 PM
MET WITH:	Mary Montiano		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Resident wandered from the facility due to lack of staff supervision
Staff did not report an incident involving resident who left facility unassisted

INVESTIGATION FINDINGS:

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On 4/5/23 Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced subsequent complaint visit in order to render findings. LPA confirmed there was no Covid-19 cases. During today’s visit LPA met with Mary Montiano and explained the purposed of the of today’s visit.

The investigation consisted of the following: On 3/9/23, LPA Brown toured the facility with the administrator. Obtained the following documents and reviewed: Resident and staff roster, C1’s needs and service, physicians Reports, resident out pass, Admission Agreement, house rules and Medical records. LPA interviewed Staff (S1-S3), Clients (C2-C7).

Investigation revealed the following:

LIC 9099 is on the next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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 11-AS-20230302152205

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNSHINE ASSISTED LIVING	FACILITY NUMBER: 198603294
	VISIT DATE: 04/05/2023

NARRATIVE

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Investigation revealed the following:

Regarding the allegation: Resident wandered from the facility due to lack of staff supervision.

On 3/9/23, LPA Brown conducted interviews with the Clients (C2-C7), Administrator Mary Montiano and Staff (S1-S4). LPA was not able to interview Client (C1) due to not being at the facility. LPA obtained the following documents: Unusual Incident report, C1’s needs and service, physicians Reports, resident’s out pass, Admission Agreement, house rules and Medical records. During interviews conducted with clients (C2-C7), clients stated they may leave the facility unsupervised and have no problems with supervision. Client (C2-C7) stated, they must fill out a pass in order to stay out of the facility for an extended period. Interviews conducted on 3/9/23 with the administrator and staff (S1-S3) stated client will need to complete a facility out pass in order to be gone for a few days. During the investigation, LPA found that on 2/22/23, a Resident Out of Pass was completed for C1 that indicated C1 will be with friends for a few days. LPA reviewed C1’s physicians report and Preplacement Appraisal, indicated C1 is alert and can leave the facility unassisted. Based on investigation there was no lack of supervision and the above allegation is unsubstantiated.

Regarding the allegation: Staff did not report an incident involving resident who left facility unassisted

On 3/9/23, LPA Brown conducted interviews with the Administrator Mary Montiano and Staff (S1-S3). LPA obtained the following documents: Unusual Incident report, C1’s needs and service, physicians Reports, resident out pass, Admission Agreement, house rules and Medical records. Interviews conducted on 3/9/23 with the administrator and staff (S1-S3). During investigation, LPA found an incident report that was submitted on 2/27/23 regarding C1 leaving facility to stay with friends and on 2/22/23 client was found being lost and was sent out to the hospital. Administrator and staff stated did not file a police report due to no knowledge that C1 was missing. LPA reviewed C1’s out pass that indicated on 2/22/23, C1 will be gone for a few days with friends. Based on investigation and interviews the above allegation is unsubstantiated.

Exit interview was conducted and a copy of the report was given to Jennifer Serrano.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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