306005223-5-12-2023-22-AS-SSAS-CRXP3M-20230518105748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005223
Report Date: 05/12/2023
Date Signed: 05/12/2023 04:30:18 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
05/08/2023 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230508113248

FACILITY NAME:	SUNNYCREST SENIOR LIVING		FACILITY NUMBER:	306005223
ADMINISTRATOR:	MELANIE WASHINGTON		FACILITY TYPE:	740
ADDRESS:	1925 SUNNY CREST DRIVE		TELEPHONE:	(714) 992-1999
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY:	210	CENSUS: 82	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	12:09 PM
MET WITH:	Melanie Washington - Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility gate is left unsecured

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced initial 10 day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Melanie Washington.

On today's visit LPA Velazquez reviewed and obtained copies of facility and resident records. LPA Velazquez also conducted interviews with residents and staff. At 12:12 PM LPA Velazquez observed a side gate next to the handicap parking area was properly secured and LPA was not able to gain entry into the facility courtyard from this gate. At 2:54 PM LPA Velazquez along with ED Washington conducted a tour of the exterior physical plant to check all of the facility doors that lead to the exterior of the facility. The one gate in question was self-closing and self-latching and was properly secured. During the course of the investigation LPA Velazquez reviewed facility and resident records as well as conducted interviews with residents and staff. The records reviewed included pictures of the side gate being left ajar with a rock in one picture near the door that has been

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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-20230508113248

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: 05/12/2023

NARRATIVE

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used to keep the gate open. Five of five individuals interviewed confirmed that they have either witnessed individuals leave the side gate ajar or have personally left the gate ajar to facilitate re-entry into the facility.

Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility gate is left unsecured is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with Resident Care Director Brenda Bravo, L.V.N. and a copy of this report along with the appeal rights and LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230508113248

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: 05/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/26/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services...for the safety and well-being of residents, employees and visitors. This requirement is not met	1 2 3 4 5 6 7	Licensee to ensure all exit gates are properly secured at all times and submit written proof to LPA by POC due date.
	8 9 10 11 12 13 14	as evidenced by: based on record review and interview the licensee did not ensure the side gate was properly secured at all times. This poses a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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