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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005223
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:23:43 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
09/27/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220927141158
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: 81DATE:
12/01/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Melanie WashingtonTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident's room has ants
Staff exposed resident to a hazardous chemical
Staff mismanaged resident's medication
Staff did not change resident's bedding
INVESTIGATION FINDINGS:
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Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Concierge Pamela Brenner. Administrator Melanie Washington was in a meeting and met with LPA at approximately 2:30pm.

On 9/24/22 R1's family discovered ants under R1's bedding covers, on her railing, and all around her bed. Staff were notified as family was leaving and stated that they would spray. The bed was sprayed with Raid by Staff #1. When family returned approximately 1.5 hr later, they found R1 in her room sitting in her chair. R1 had not been removed from the room and there were dead ants on the sheets, and there was a puddle of ant spray on the floor. The sheets had also not been changed. R1's family took R1 home for the rest of the weekend. R1's medications were given to the family for the days R1 would be gone. The medication given was incorrect. A double dose had been given. When LPA inspected the MAR there was no documentation that R1 had gone home.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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-20220927141158
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: 12/01/2022
NARRATIVE
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Based upon interviews and a review of records, the preponderence of evidence standard has been met and the therefore the above allegation is found to be SUBSTANTIATED.

See LIC 9099D for cites deficiencies 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 with Administrator Melanie Washington.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20220927141158
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: 12/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2022
Section Cited
CCR
87307(d)(2)
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Personal Accomodations and Services-The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement was not met as evidenced by:
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Licensee agrees to spray for ants and ensure that resident rooms are checked often to ensure that after a spray ants are not making their way into resident rooms.

Facility has pest control in place and maintenance sprays when needed.
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On 9/24/22 R1 had ants in her bed sheets, on the railing of her bed and on her floor.

This posed an immediate health and safety and personal rights risk to residents in care.
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Type A
12/02/2022
Section Cited
CCR
87468.1
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Personal Rights of Residents-The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement was not met as evidenced by:
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Licensee agrees to train staff on the proper use of ant spray to make sure that residents are not exposed.


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On 9/24/22 S1 sprayed R1's room with ant spray and did not remove R1 from the room.

This posed an immediate Health and Safety and Personal Rights 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) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20220927141158
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: 12/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2022
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Administrator agrees to retrain all staff on proper medication managment and if a MAR is used, it should be completed correctly.

Proof will be provided of training.
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On 9/24/22, R1 went home with family for 2 days and medications were sent with the resident. According to family the resident received a double dose of medication. LPA also noted through a records review that the MAR was not documented correctly. The MAR was initialed that staff gave R1 medication however R1 was not present.
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Type A
12/02/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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Licensee/Administrator agrees to change resident bedding immediately as soon as it is discovered that it is soiled, especially after being sprayed with ant poison.

Certification of understanding will be provided,

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On 9/24/22, R1's sheets were not immediately changed when it was discovered that R1 had ants in her bed. Staff sprayed Raid and did not immediately change the sheets.

This poses an immediate health and safety risk.
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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) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4