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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005223
Report Date: 11/18/2021
Date Signed: 11/18/2021 02:38:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
306005223
ADMINISTRATOR:HEATHER YOSTFACILITY TYPE:
740
ADDRESS:1925 SUNNY CREST DRIVETELEPHONE:
(714) 992-1999
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:210CENSUS: 87DATE:
11/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Heather Yost, Executive DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Kathrina Chin to follow up on incident reported to Community Care Licensing on 11/9/2021 regarding multiple falls concerning resident 1. LPA arrived at facility and informed receptionist of visit. LPA spoke with Heather Yost, Executive Director and explained the nature of the visit on the telephone. Ms. Yost arrived at the facility within one hour. LPA interviewed resident 1. The facility did not report to the licensing agency when resident fell, hit the back of her head on the rails of the bed and 911 emergency was not contacted within 7 days of the occurrence.

The following deficiency is cited today as per Title 22 of the California Code of Regulations:

An exit interview was conducted and a copy of this report was left at the facility and appeal rights were provided.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2021
Section Cited

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Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence..
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Based on observation and file review the facility staff failed to report the incident within seven days of the fall when resident 1 sustained an unwitnessed fall on 11/9/2021 and 911 emergency personnel was contacted.This poses a potential threat to the health, safety and/or personal rights to the resident 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: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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