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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603294
Report Date: 01/10/2024
Date Signed: 01/10/2024 01:14:57 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
01/09/2024 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240109084854
FACILITY NAME:SUNSHINE ASSISTED LIVINGFACILITY NUMBER:
198603294
ADMINISTRATOR:MARY MONTIANOFACILITY TYPE:
735
ADDRESS:3141 EUCLID AVETELEPHONE:
(310) 638-3847
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:68CENSUS: 58DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Mary MontianoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident engaging in a physical altercation with another resident causing injury.
INVESTIGATION FINDINGS:
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On 01/10/2024 at around 8:45 AM Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Regina Cloyd initiated a complaint investigation regarding the allegation listed above. LPM and LPA meet with Administrator Mary Montiano and the purpose of the visit was explained.

The investigation consisted of the following: During today’s investigation LPM, LPA, and Administrator conducted a tour of the Annex Building (Building #2). LPM and LPA interviewed 8 out of 58 clients and 5 staff which included the Administrator, Business Manager, Lead Caregiver, MedTech, and Caregiver. Client C2 was not present at the facility and was not able to provide an interview. LPM and LPA reviewed the caregivers' schedule, client roster, 3 client records, 2 staff records, and incident records.

Continue to LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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 11-AS-20240109084854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUNSHINE ASSISTED LIVING
FACILITY NUMBER: 198603294
VISIT DATE: 01/10/2024
NARRATIVE
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The investigation revealed the following:
Regarding the allegation "Staff did not provide adequate supervision resulting in resident engaging in a physical altercation with another resident causing injury," The investigation revealed that an altercation between clients happened inside client C1's bedroom. Interviews conducted indicated the following: Five out of five staff interviews indicate that facility has adequate staffing, staff S3 indicated that visual checks are conducted every four (4) hours in clients bedroom to ensure that clients are okay and that constant monitoring is conducted in the common areas. 8 out of 8 client interviewed indicate that there is adequate staffing, 7 out of 8 clients indicated that they felt safe living at the facility. Record reviews of clients C1 and C2's record indicate that they did not have histories of behavioral issues or that they needed for additional supervision.

Regarding the allegation "Staff did not provide adequate supervision resulting in resident engaging in a physical altercation with another resident causing injury," the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated.

No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Mary Montiano.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2