306004562-4-29-2022-22-AS-AORZ-CGAMYF-20220713100129

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004562
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:18:12 AM

Unsubstantiated

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
12/30/2020 and conducted by Evaluator Rosie Quiroz

COMPLAINT CONTROL NUMBER: 22-AS-20201230171404

FACILITY NAME:	SUNRISE OF SEAL BEACH		FACILITY NUMBER:	306004562
ADMINISTRATOR:	LUIS RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	3850 & 3840 LAMPSON AVE		TELEPHONE:	(562) 594-5788
CITY:	SEAL BEACH	STATE: CA	ZIP CODE:	90740
CAPACITY:	261	CENSUS: 125	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Luis Rodriguez, Executive Director and Marlen Arguero Hernandez, Associate Executive Director.		TIME COMPLETED:	11:17 AM

ALLEGATION(S):

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-Facility staff failed to notify R1's doctor about a change in condition

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz made an unannounced visit on this day for the purpose of delivering findings for a complaint investigation. LPA Quiroz met with Executive Director Luis Rodriguez and Marlen Arguero Hernandez, Associate Executive Director.
It was alleged that facility staff failed to notify R1's doctor about a change in condition. The investigation determined the following:
During the course of this investigation, LPA Quiroz reviewed documents for Resident 1 (R1): Optum Care Telephone message documentation dated December 22, 2020 through January 4, 2021, Email correspondence dated December 17, 2020 at 2:03pm, December 17, 2020 at 4:22pm, December 18, 2020 at 11: 26am and December 19, 2020 at 11:50am, Physician Report dated June 27, 2019, Individual Service Plan, Progress Notes dated December 1, 2020 through January 19,2021 and multiple interviews with 6 interviewees.

Continued on next page...

Unsubstantiated

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: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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-20201230171404

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 SEAL BEACH	FACILITY NUMBER: 306004562
	VISIT DATE: 04/29/2022

NARRATIVE

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The investigation revealed that R1’s responsible party was notified of R1's change of condition via telephone voicemail on 12/16/2020 and email dated 12/17/2020 at 4:22pm addressed to (R1’s) responsible party indicating the following: “Your mom received an “inconclusive” result on testing we did 12/11/20. This means she had small traces of COVID. It is for that reason we kept her in the apartment. She then was tested again on 12/14/20 and her result was positive. Your mom’s symptoms began late Friday night with an elevated temperature. As of today your mom is not demonstrating any additional fevers. She appears to be doing fine. Just a side note, I am not at the community as I have fallen ill and am quarantining. This is the reason I am asking families to email so I can respond to them, while the team is providing the care.”
R1 was initially tested positive for COVID on 12/14/2020. Two of two interviewees indicated that R1's Primary Care Physician Gregory Kimball (PCP) was notified of R1’s change of condition on 12/14/2020 via verbal telephone call conducted by former Health Wellness Director (HWD) Brian Wilson. However, no written proof of notice could be provided. Facility staff failed to document notice in writing to resident’s PCP. (HWD) Wilson’s verbal telephone call with R1’s PCP could not be confirmed with PCP office.
R1 passed away at the facility on 12/21/2021 at 3:10am in their sleep. Due to the facility being a non-medical facility, the facility reported R1’s death by sleep to the PCP office, who issued R1’s death certificate. It was only after speaking with R1’s responsible party that the PCP reported being unaware of R1’s COVID status and updated R1’s death certificate. Due to conflicting information as to if R1’s PCP was notified of R1’s COVID diagnosis, R1’s final cause of death was delayed.
It was alleged that “Facility staff failed to notify (R1’s) doctor about a change in condition. Based on the review of documentation gathered and interviews conducted with 6 of 6 interviewees, it was unclear if "Facility staff failed to notify (R1's) doctor about a change in condition"; therefore, the allegation was found to be unsubstantiated. Although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation was deemed UNSUBSTANTIATED.
An exit interview was conducted with Executive Director Luis Rodriguez and Marlen Aguero Hernandez, and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC9099 (FAS) - (06/04)

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