306005223-9-22-2022-22-AS-SSAS-CKD2WV-20221019174609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005223
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:09:20 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
08/08/2022 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220808092134

FACILITY NAME:	SUNNYCREST SENIOR LIVING		FACILITY NUMBER:	306005223
ADMINISTRATOR:	SARAH CLEESEN		FACILITY TYPE:	740
ADDRESS:	1925 SUNNY CREST DRIVE		TELEPHONE:	(714) 992-1999
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY:	210	CENSUS: 85	DATE:	09/22/2022
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Melanie Washington, Executive Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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1)Facility mismanaged resident's medication.
2)Facility failed to provide competent staff to meet resident's needs.

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 July 29, 2022, two responsible parties of R1 was visiting R1 at the facility. An evening shift agency Medication Technician, Staff 1, was giving R1 medications. The two family members noticed that R1 was being given the wrong medications. R1 was being given another resident's (R2)medications. Staff 1 was giving R1 Senna and Citalopram. LPA interviewed Staff 1 who stated that the R1 and R2's medications were switched accidently by facility staff inside the medication carts. S1 demonstrated to LPA on how R1 and R2's medications got switched. LPA observed the facility relies on giving medications based on labels of room numbers inside the medication carts. LPA also reviewed the medication list and reviewed R1 and R2 medications. It is unclear as to how many days that R1 may have been given R2's medications.

(Continued LIC 9099)

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: 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)

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Control Number 22-AS-20220808092134

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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R1's responsible party stated that the Medication Technician, Staff 1, only had the tackle box with her into the resident 1's room. Staff 1 did not have the medication cart with the laptop in order to check the medication. Staff 1 had to return to the medication room, bring the medications and showed the medications to the two responsible parties. This is when the medication error was discovered. Photographs were taken of the two medications about to be given to R1.

Based on the information gathered during the investigation and review of all documents obtained, the following allegations: 1)Facility mismanaged resident's medication.
2)Facility failed to provide competent staff to meet resident's needs.

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: 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: 2 of 3

Control Number 22-AS-20220808092134

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 87465(a)(5)(A)	1 2 3 4 5 6 7	Incidental Medical and Dental Care... Assistance with self-administered medications shall be limited to … medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	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
	8 9 10 11 12 13 14	Based on the file review, observations and interviews, the facility, Staff 1 admitted that she was about to give R1 another resident's medication(R2). S1 was about to give R1 on 7/29/22, Senna and Citalopram which is not her medications and not authorized or ordered by her physician. This poses an immediate health & safety risk to residents in care	8 9 10 11 12 13 14
Type A 09/23/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements- 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, and interviews, staff 1 failed to demonstrate competency in dispensing medications as S1 did not	1 2 3 4 5 6 7	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
	8 9 10 11 12 13 14	have the medication cart with laptop in order to check if she was passing out R1 medication properly. Staff had to go the medication room and bring down the medications and found out she was giving R1 another resident medications. S1 was relying on solely room numbers in passing out medications.This poses an immediate health & safety risk to residents in care	8 9 10 11 12 13 14

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: 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)

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