306002644-4-5-2022-22-AS-AORZ-CMCVLB-20221222153139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002644
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:07:54 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
10/26/2021 and conducted by Evaluator Rosie Quiroz

COMPLAINT CONTROL NUMBER: 22-AS-20211026112550

FACILITY NAME:	SUNRISE OF MISSION VIEJO		FACILITY NUMBER:	306002644
ADMINISTRATOR:	PSENECNIK, ROXANNE		FACILITY TYPE:	740
ADDRESS:	26151 COUNTY CLUB DR		TELEPHONE:	(949) 582-2010
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	110	CENSUS: 85	DATE:	04/05/2022
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Lucy Yi, Business Office Coordinator, Patti Darsow, Director of Sales and Roxanne Psenicnik, Executive Director		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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-Facility is understaffed

INVESTIGATION FINDINGS:

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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to conclude this agency’s investigation into the complaint allegation mentioned above. LPA Rosie Quiroz arrived to the facility was COVID-19 screend and met with Business Office Director Lucy Yi. Director of Sales Patty Darsow joined the inspection tour on or about 10:18am. Executive Director Roxanne Psenicnik arrived on or about 10:47am.
During the course of the investigation, LPA requested resident roster, staff schedules for October 2021-December 2021, Staff roster with contact phone numbers, Physician reports, Needs and Services Plans, and Identification Forms for Resident 1 (R1), Resident 2 (R2), Resident 3 (R3) and Resident 4( R4).
During the initial visit LPA Quiroz also met with Thais Andrade Souza, Interim Executive Director (IED) and Ruby mendez, Assisted Living Coordinator who both confirmed that staffing has been a challenge due COVID-19 Pandemic, but denied that the resident’s needs were not being met. (IED) Thais Andrade Souza indicated that facility always have staff to cover the vacancies, so that there are always enough staff present to meet the needs of residents in care. CONTINUED ON NEXT PAGE...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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 4

Control Number 22-AS-20211026112550

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 OF MISSION VIEJO	FACILITY NUMBER: 306002644
	VISIT DATE: 04/05/2022

NARRATIVE

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CONTINUED...
During the course of the investigation, LPA Rosie Quiroz interviewed Twelve interviewees. Twelve of Twelve interviewees indicated that facility is always experiencing staff shortages in “Reminiscence” Memory Care Unit. Twelve of Twelve interviewees indicated that when there’s a call off, staff have to work short which leads to resident’s needs not being met timely.”
During today’s visit, on or about 9:52am, LPA Quiroz along with Lucy Yi, Business Office Director (BOD) toured The Reminiscence neighborhood Memory Care Unit. On or about 9:59am, while conducting inspection tour along with (bod) Yi, LPA Quiroz pulled chord in Room 316 at 9:59am. This was verified with (BOD) Lucy Yi. On or about 10:00am, while touring dining-room area with (BOD) Lucy Yi , LPA Quiroz observed 20 residents of which 16 of 20 residents were observed on the right side of dining-room unsupervised by staff and 4 of 20 residents on the left side of dining-room eating their breakfast supervised by Lead Care Manager.
On or about 10:03am, LPA Quiroz observed vomit on Resident 2 (R2) and on floor area near (R2). On or about 10:04am, LPA Quiroz observed Resident 3 (R3) yelling "Want a drink." LPA Quiroz observed no staff supervising 16 of 20 residents sitting on right side area in dining room area. This was verified with (BOD) Lucy Yi. On or about 10:07am, LPA Quiroz inquired staffing ratio and numbers of staff present today. Lead Care Manager on duty verified that there were 2 Care Managers and 1 Lead Care Manager working today and indicated “1 agency staff called out today and no one showed up. Memory Care Director was informed.”
During today’s visit, Medication Technician on duty was observed conducting medication technician duties. During today’s inspection tour visit it was reported by Lead Care Manager that 1 of 2 care Managers working on today’s date was out on break.
During today’s visit, on or about 10:18am Director of Sales (D0S) Patty Darsow joined inspection tour. At this time Life Enrichment Manager was observed coming into the neighborhood to commence her assigned shift. LPA Quiroz along with Patty Darsow toured Room #13. On or about 10:19am, LPA Quiroz pulled call light chord in Room #13. LPA Quiroz and (DOS) Darsow waited until approximately 10:26am and no staff responded to call light. On or about 10:27am, LPA Quiroz and (DOS) Darsow walked back to dining-room area and inquired about call light services. Lead Care Manager pulled out her phone and said “Oh, Room #16 and Room #13 need help.” (DOS) Darsow asked Lead Care Manager and Agency Staff “How do you know residents need help or pulling chord?” Lead Care Manager then checked her phone and identified there were 2 call lights requiring assistance. The Lead Care Manager indicated that calls lights are identified via telephone and that Agency Staff did not have telephone access on today’s date. On or about 10:29am, LPA Quiroz observed Lead Care Manager give directive to Agency Staff to respond to call lights in Room #13 and Room #16 that were initiated at 9:59am and 10:19am. CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20211026112550

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 OF MISSION VIEJO	FACILITY NUMBER: 306002644
	VISIT DATE: 04/05/2022

NARRATIVE

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CONTINUED...

On or about 12:26pm, LPA Rosie Quiroz inquired about Agency Staff who had called out. (ED) Roxanne Psenicnik verified “I had another coordinator fill in until the Agency Staff arrived." COVID-19 check in screened verified, Staffing Agency arrived to facility on or about 11:33am. At 12:28pm, Executive Director Roxanne Psenicnik verified 22 of 24 residents in Reminiscence Memory Care Unit have a Dementia diagnose.

Based on the information gathered through interviews, records reviewed, and observations conducted during today’s visit, the preponderance of evidence standard has been met therefore the above allegation is Substantiated.

The following deficiency is being cited per Title 22, Div. 6 of the California Code of Regulations. (See Lic 809-D). This report, along with Appeal Rights and LIC 809-D were discussed with Executive Director Roxanne Psenicnik and provided via email.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20211026112550

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 OF MISSION VIEJO	FACILITY NUMBER: 306002644
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/08/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: On or about 10:00am, while touring dining-room area with (BOD) Yi CONT...	1 2 3 4 5 6 7	(ED) Roxanne Psenicnik agreed to provide training on call light services response time to Facility and Agency Staff, and will provide CCLD with tool utilized and description of functionality in creating adequate staffing to meet resident's needs. ED will sibmit call off process follow up for NO SHOW staff by POC 4/8/2022 COB.
	8 9 10 11 12 13 14	LPA Quiroz observed 16 of 20 residents on the right side of dining-room unsupervised by staff.On or about 10:28am, LPA Quiroz and (DOS) Patty Darsow walked back to dining-room area and inquired about call light services. Lead Care Manager pulled out her phone and said “Oh, Room #16 and Room #13 need help.” CONT	8 9 10 11 12 13 14	On or about 10:29am, LPA Quiroz observed Lead Care Manager give directive to Agency Staff to respond to call lights in Room #13 and Room #16 that were initiated at 9:59am and 10:19am. This poses an immediate risk to residents 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

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