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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005223
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:30:15 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
08/23/2022 and conducted by Evaluator Kathrina Chin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220823113818
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: 75DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Melanie Washington, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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1) Resident's room has roaches.
2) Facility is dirty.
3) Resident's closet and blinds is in disrepair.
4) Staff did not ensure the facility front doors were locked for safety of residents.
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.

The investigation into the above allegations revealed the following:

LPA interviewed Resident 1, Witness 1 (W1) and Witness 2(W2). LPA also reviewed photographs which showed two roaches inside the R1's room. The Building Director confirmed that the facility does have roaches at various locations and have sprayed several rooms. Witness 2 (W2) reported that R1's room was very dirty, the closet was off tract and the two slots on the blinds above the sliding door were missing. On August 24, 2022, LPA inspected R1's room and the carpet needed to be vacuumed. LPA observed resident's closet door was off the track and was difficult to open. Two slots were missing from the sliding door blinds. (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: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 6
Control Number 22-AS-20220823113818
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: 09/23/2022
NARRATIVE
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Witness 2 stated that he observed the front door unlocked on August 18, 2022 at 10:17 PM. Witness 2 provided a video that the front door was unlocked.

Based on the information gathered during the investigation and review of all documents obtained, the following allegations are substantiated: Resident's room has roaches. Facility is dirty.
Resident's closet and blinds is in disrepair. Staff did not ensure the facility front doors were locked for safety of residents.

Based on LPA's observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegations are 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: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
08/23/2022 and conducted by Evaluator Kathrina Chin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220823113818

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: 75DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Melanie Washington, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure that resident had a key to lock her room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kathrina Chin made an unannounced visit to investigate the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director, Melanie Washington.

The investigation into the allegation that staff did not ensure resident had a key to lock her room are the following:

LPA, Kathrina Chin interviewed the Building Services Director(S1) who stated that he made a key for resident 1 when he received the work order for it. He said that a key is easily made since he has the machine to make it. The Building Services Director, S1 stated that he gave it to the resident as soon as it was made. The responsible party confirmed that R1 did receive the key. (Continued on LIC 9099C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 6
Control Number 22-AS-20220823113818
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: 09/23/2022
NARRATIVE
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Based on the above findings, this allegation is determined to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

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

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20220823113818
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: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited
CCR
87468.1
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Personal Right of Residents in all Facilities- To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not being met as evidenced by: Based on record review, and interviews, Witness 1 observed the front door to be unlocked at 10:17 PM on August 18, 2022.
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Melanie Washington, Executive Director stated that night staff have been trained to close the sliding front door and that back gate is also closed at night. Staff will need to check on the security of the building every two hours.
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Staff stated that they did not know how to lock the front automatic sliding door. This poses an immediate health & safety risk to residents in care.
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Type B
09/30/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation-(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by: Based on record review, and interviews, R1's room was observed to be dirty and had two roaches.
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The Maintenace Director has fixed the closet door and the two blinds were ordered.
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R1's closet door was off track and was difficult to open. Two blinds were missing on the sliding door blinds. This poses a potential 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: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6