306002568-10-18-2022-22-AS-SSAS-CKUVDA-20221104162025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002568
Report Date: 10/18/2022
Date Signed: 10/18/2022 04:51:46 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2022 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220802112448

FACILITY NAME:	SUNRISE AT YORBA LINDA		FACILITY NUMBER:	306002568
ADMINISTRATOR:	MARIA DOMINGO		FACILITY TYPE:	740
ADDRESS:	4792 LAKEVIEW AVE		TELEPHONE:	(714) 693-5368
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	93	CENSUS: 65	DATE:	10/18/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Tyler Hawk, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility does not follow COVID-19 protocol.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin conducted an unannounced visit for the purpose of delivering the findings on a complaint investigation. LPA met with Tyler Hawk, Executive Director.

The investigation into the allegation that facility does not follow COVID-19 protocol is the following:

During the initial visit on August 10, 2022, LPA Chin observed one staff member who had her mask on but was underneath her chin. This employee was in the Activity Center with several residents. Two staff members from the kitchen had their surgical mask on their chins and were not wearing them properly. LPA interviewed two staff members who indicated that they have observed facility employees to be wearing masks at times. (Continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

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 22-AS-20220802112448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNRISE AT YORBA LINDA	FACILITY NUMBER: 306002568
	VISIT DATE: 10/18/2022

NARRATIVE

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The facility had several COVID-19 positive individuals in the Assisted Living section of the facility during the month of July 2022.

Based on LPA's observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are cited today as per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted along with appeal rights were provided and a copy of this report was left .

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220802112448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNRISE AT YORBA LINDA	FACILITY NUMBER: 306002568
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/21/2022 Section Cited CCR 87465(a)(9)	1 2 3 4 5 6 7	Incidental Medical and Dental Care- The licensee shall ensure that infection control practices are maintained in the facility as specified in Section 87470, Infection Control Requirements. This requirement is not being met as evidenced by: Based on interviews and observations, LPA observed three staff members who were not wearing masks properly.	1 2 3 4 5 6 7	Tyler Hawk, Executive Director stated that in-service training for all staff have already been completed on August 25, 2022. This deficiency is cleared.
	8 9 10 11 12 13 14	The licensee did not ensure that the infection control practices were maintained and implemented at the facility. This poses a potential risk to the residents in care.	8 9 10 11 12 13 14
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	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.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC9099 (FAS) - (06/04)

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