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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005223
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:58:24 AM


Document Has Been Signed on 02/15/2024 10:58 AM - It Cannot Be Edited

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:AGUIRRE, MONICAFACILITY TYPE:
740
ADDRESS:1925 SUNNY CREST DRIVETELEPHONE:
(714) 992-1999
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:210CENSUS: 89DATE:
02/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Melanie Washington, Executive DirectorTIME COMPLETED:
11:00 AM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA Quiroz was greeted and granted entry into the facility by front desk receptionist and met with Melanie Washington, Executive Director and explained the reason for the visit. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency.

Resident 1 (R1) was admitted to the facility on April 1, 2023. Per R1’s Physician report dated June 8, 2023 resident is not able to administer or store their own medication. On August 12, 2023, Staff 1 (S1) reported being busy finishing tasks before the end of their shift and passed off medication duty to another MedTech, Staff 2(S2), to finish distributing. S1 reported placing R1’s medication with Resident 2 (R2)’s, medication into white cups with their room numbers written on it. S1 signed off on both R1 and R2 taking their medications based off word of mouth from S2. S1 and S2 did not physically see residents take their medications.

On the morning of August 13, 2023, R1 saw a white cup with medications on the nightstand and assumed they were for them and ingested them. When S1 came in to do R1’s morning medication disbursement, S1 found out S2 had left medications for R2 on R1’s dresser and didn’t distribute them like they had said they did the night before. Shortly after taking the wrong medications, R1 became lethargic and unresponsive and was transported to St. Jude Hospital and returned to the facility later that night.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, 809-D Page, and appeal rights was left at the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/15/2024 10:58 AM - It Cannot Be Edited

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: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2024
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. CONT BELOW...
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Facility hired a medication room manager in addition to MT's to ensure proper medication administration. AD agreed to provide inservice training to all staff identied on LIC 500 on CCR 87465 by POC due date of 2/20/2024.
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This requirement was not met as evidence by: Licensee failed to ensure medications were locked inaccessible to R1 resulting in R1 ingesting another resident’s medication. This poses an immediate health and 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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