306005424-9-17-2021-22-AS-SSAS-C7S2P6-20211013173345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005424
Report Date: 08/13/2021
Date Signed: 09/17/2021 11:27:59 AM

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
07/10/2020 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200710153801

FACILITY NAME:	SUNRISE VILLA BRADFORD		FACILITY NUMBER:	306005424
ADMINISTRATOR:	CALABRESE, RUZICA		FACILITY TYPE:	740
ADDRESS:	1180 & 1176 N BRADFORD AVE		TELEPHONE:	(703) 273-7500
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	136	CENSUS: 78	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator Ruzica Calabrese		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility accepted a resident who required a higher level of care
Facility staff refused to accept resident back from the hospital

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of the complaint investigation. Upon arrival, LPA met with Administrator Ruzica Calabrese. The investigation consisted of interviews conducted with the facility staff, Administrator, and witnesses as well as documentation. The following was determined:

Resident #1(R1) was admitted into the facility on 6/11/20 and resided in the Terrace Club. The Terrace Club is the Memory Care building at the facility and is approved for delayed egress. R1 would exit seek everyday and was aggressive with staff and other residents. On 7/7/20 R1 pushed and kicked the outside gate and was able to exit. Staff followed R1 and the police and R1’s responsible party were contacted. R1 was returned to the Community with no injuries. Staff informed the responsible party that a higher level of care was needed for R1 and assistance was provided for possible relocation of R1.

On 7/8/20 R1 placed a chair against the outside wall of the facility and attempted to climb over. Staff

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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-20200710153801

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: SUNRISE VILLA BRADFORD	FACILITY NUMBER: 306005424
	VISIT DATE: 08/13/2021

NARRATIVE

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intervened and R1 became aggressive. 911 was contacted and R1 was combative with police. R1 was transported to the hospital. R1 did not return to the facility due to the level of care he required.

Based upon interviews and a review of R1's records, these allegations are unsubstantiated, meaning that although the allegations are valid, there is not a preponderance of the evidence to prove that the facility staff knew that R1 required a higher level of care when R1 was admitted. Staff did refuse to take R1 back to the facility because R1 was engaging in behavior that was a threat to his mental and/or physical health. R1 went home with family and did not return.

An exit interview was conducted with Administrator Ruzica Calabrese and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
07/10/2020 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200710153801

FACILITY NAME:	SUNRISE VILLA BRADFORD		FACILITY NUMBER:	306005424
ADMINISTRATOR:	CALABRESE, RUZICA		FACILITY TYPE:	740
ADDRESS:	1180 & 1176 N BRADFORD AVE		TELEPHONE:	(703) 273-7500
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	136	CENSUS:	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator Ruzica Calabrese		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Lack of supervision resulting in resident wandering away from the facility

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of the complaint investigation. Upon arrival, LPA met with Administrator Ruzica Calabrese. The investigation consisted of interviews with facility staff, Administrator, and witnesses as well as a review of records. The following was determined:

Resident #1(R1) was admitted into the facility on 6/11/20 and resided in the Terrace Club. The Terrace Club is the Memory Care building at the facility and is approved for delayed egress. R1 would exit seek everyday and was aggressive with staff and other residents. On 7/7/20 R1 pushed and kicked the outside gate and was able to exit. Staff followed R1 and the police and R1’s responsible party were contacted. R1 was returned to the Community with no injuries.

Based upon interviews and a review of records, the allegation above is unfounded, meaning the allegation was false, could not have happen or is without reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted and a copy of this report was provided to Ruzica Calabrese.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

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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