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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005223
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:25:50 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
08/30/2022 and conducted by Evaluator Kathrina Chin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220830115230
FACILITY NAME:SUNNYCREST SENIOR LIVINGFACILITY NUMBER:
306005223
ADMINISTRATOR:SARAH CLEESENFACILITY TYPE:
740
ADDRESS:1925 SUNNY CREST DRIVETELEPHONE:
(714) 992-1999
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:210CENSUS: 85DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Melanie Washington, Executive DirectorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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 Medication Technicians are not properly trained.
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 Melanie Washington, Executive Director.


On August 23, 2022, Staff 1 stated that she was passing out residents medications on the first floor. While in the diningroom, S1 said that she had three residents who were in their rooms on the first floor that have not received their medications. She left the medication cart with the laptop in the dining room. She took the three medications of the residents and proceeded to pass the medications. She entered R1's room and the Ombudsman Representative and R1 was also inside. The Ombudsman Representative asked S1 for the name of the resident she was giving the medications to, room number and what medications she was giving. S1 was unable to answer because she left the medication cart with the computer with the E-MARs and residents pictures in the dining room. Staff 1 stated that she being shadowed on August 23, 2022 by Staff 2 but S2 was passing medications on the second floor. Staff 1 stated that she has worked for the facility for about three weeks and she is new to the facility. (Continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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 5
Control Number 22-AS-20220830115230
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: SUNNYCREST SENIOR LIVING
FACILITY NUMBER: 306005223
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not being met as evidenced by: Based on observation, record review, and interviews, staff 1 failed to demonstrate competency in dispensing medications as S1 did not know the name of the resident, room number
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 Melanie Washington, ED stated that all Medication Technicians will receive in-service training on Medication dispensing and the medication cart will be utilized with laptop containing eMars and residents photos while assisting residents with medications. A civil penalty , LIC 421, is assessed today. This is a repeat violation and deficiency.
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 medications because she left the medication cart with laptop the dining room on August 23, 2022. Staff went to R1's room to dispense her medications. Staff 1 is a new employee and has worked for the facility about three weeks and is not familiar with all the residents. S1 did not follow the facility's medication training and procedure. This poses an immediate health & safety 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: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/30/2022 and conducted by Evaluator Kathrina Chin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220830115230

FACILITY NAME:SUNNYCREST SENIOR LIVINGFACILITY NUMBER:
306005223
ADMINISTRATOR:SARAH CLEESENFACILITY TYPE:
740
ADDRESS:1925 SUNNY CREST DRIVETELEPHONE:
(714) 992-1999
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:210CENSUS: 78DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Melanie Washington, Executive DirectorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff are not administering resident's medication as prescribed.
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 Melanie Washington, Executive Director.

LPA, Kathrina Chin interviewed Staff 1(S1) and Staff 2(S2) who are both Medication Technicians. S1 and S2 stated that they pre-poured the medications for resident 1. S1 was shadowing S2 and both stated that the medications given to R1 was correctly pre-poured for R1. LPA reviewed R1's medication list. R1 was also interviewed.

Based on the information gathered during the investigation and review of all documents obtained, the following allegations: Staff are not administering resident's medication as prescribed is deemed Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220830115230
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: SUNNYCREST SENIOR LIVING
FACILITY NUMBER: 306005223
VISIT DATE: 09/22/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted, appeal rights explained and provided. A copy of this report was provided during the visit to Melanie Washington, Executive Director.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220830115230
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: SUNNYCREST SENIOR LIVING
FACILITY NUMBER: 306005223
VISIT DATE: 09/22/2022
NARRATIVE
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S1 admitted that she is a new Medication Technician and was unfamiliar with all the residents and should have had the medication cart with the laptop with her at all times. The computer contains the resident's name with pictures, medication list, room numbers and other pertinent information.

Based on the information gathered during the investigation and review of all documents obtained, the following allegations: Medication Technicians are not properly trained is substantiated.

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 SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5