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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005223
Report Date: 05/09/2022
Date Signed: 05/10/2022 07:58:37 AM


Document Has Been Signed on 05/10/2022 07:58 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:SARAH CLEESENFACILITY TYPE:
740
ADDRESS:1925 SUNNY CREST DRIVETELEPHONE:
(714) 992-1999
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:210CENSUS: 83DATE:
05/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Sarah Cleesen, Executive DirectorTIME COMPLETED:
05:00 PM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Kathrina Chin to follow up on a death reported to Community Care Licensing on 05/02/22 for the death of a resident on 5/1/22. LPA arrived at facility and informed the receptionist of the visit. LPA met with Sarah Cleesen, Executive Director and explained the nature of the visit.

During the visit, LPA obtained copies of the following documents pertaining to resident (R1): physician's report, Needs and Services Plan, death report, and pre-admission assessment.

R1 resided in the facility since 1/7/22. Resident was on hospice care with Sunlight Hospice for heart disease. Resident is able to ambulate independently with a walker.

According to Ms. Cleesen, staff found resident 1 on 5/1/22 on the floor and the resident was blocking the door with her walker tipped over next to the resident. The bathroom door and entrance door are close together.

Today, LPA interviewed staff 1 who found R1 first that morning. S1 stated that he tried to open the door at about 7 am on 5/1/22 and the door opened about a third of the way. S1 said that called the S2 who is a Medication Technician and S2 called 911 emergency personnel. S1 stated that he continued his work with other residents when the 911 emergency personnel and the police arrived. Ms. Cleesen said that resident 1 had a DNR.

The caregiver called the Medication Technician. The Medication Technician called 911 emergency personnel.

At this time, based on the information available, there are no deficiencies cited this review as per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was given to Sarah Cleesen, Executive Director.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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