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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603294
Report Date: 12/19/2024
Date Signed: 12/19/2024 09:19:38 AM

Document Has Been Signed on 12/19/2024 09:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SUNSHINE ASSISTED LIVINGFACILITY NUMBER:
198603294
ADMINISTRATOR/
DIRECTOR:		MARY MONTIANOFACILITY TYPE:
735
ADDRESS:3141 EUCLID AVETELEPHONE:
(310) 638-3847
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 68CENSUS: 55DATE:
12/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:MARY MONTIANOTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
NARRATIVE
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On 12/19/2024 the Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an unannounced Case Management – Deficiency visit and met with ADMINISTRATOR MARY MONTIANO. The purpose of this visit is to issue citations on violations of Title 22 Regulations observed during an investigation for a complaint with complaint number 11-AS-2024725103218. During the investigation, records were reviewed, and interviews were conducted with facility clients and (current and former) staff. Reviews of St. Francis Hospital medical records revealed client R1 sustained a closed femoral neck fracture. The interview of R1 revealed he required assistance to get up after the fall. The interview of former staff S3 revealed on 07/21/2024 (the day of the incident) at approximately 10:30 PM, another client informed her that R1 had an unwitnessed fall. S3 stated she immediately responded to assess R1 who presented a change in condition as he was unable to ambulate. S3 stated R1 refused medical attention even though he immediately reported believing he had broken his hip and was in a lot of pain. S3 stated she called her supervisor S1 to report the incident and was instructed to request a non-emergency ambulance. The interview of caregiver supervisor S1 revealed that all staff had the authority to call 911 when they deemed necessary. S1 further stated S3 contacted her and informed her even though R1 refused medical attention,
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SUNSHINE ASSISTED LIVING
FACILITY NUMBER: 198603294
VISIT DATE: 12/19/2024
NARRATIVE
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 S3 believed he needed to be medically assessed. S1 stated that given the circumstances (R1 had just returned to the facility from another fall and there change in condition), 911 should have been called. However, S1 did not advise S3 to call 911 when S3 reported the incident. The review of the non-emergency ambulance records revealed the ambulance arrived at the facility on 07/22/2024, at 10:01 AM and subsequently to R1’s room at 10:22 AM (approximately 10 hours after the incident). R1 may have been spared the additional pain associated with the injury if medical attention was immediately sought after the incident. The facility failed to seek medical attention in a timely manner when Client/R1 sustained a serious injury (hip fracture) while in care, Title 22, Division 6, Chapter 1 is being cited please see LIC809D. A civil penalty is being assessed, please see LIC421IM. An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to MARY MONTIANO.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2024 09:19 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Jose Calderon On 12/19/2024 at 09:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SUNSHINE ASSISTED LIVING
FACILITY NUMBER: 198603294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/20/2024
Section Cited
CCR
80065(f)(5)

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80065(f)(5) Personnel Requirements. All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. Recognition of early signs of illness and the need for professional assistance. This requirement was not met as evidenced by:

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The administrator agrees to conduct an in-service training to all staff discussing Title 22 80065(f)(5) Personnel Requirements. Proof of Correction will be submitted to LPA Calderon via email within 24-hours.

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Based on record reviews and interviews the licensee failed to ensure that S1 and S3 recognized the need for professional help for R1 after an unwitnessed fall which poses an immediate health and safety and personal rights risk to clients in care.

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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Jose Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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