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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006411
Report Date: 05/08/2026
Date Signed: 05/08/2026 04:15:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/06/2026 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260506115738
FACILITY NAME:SUNNY VILLAFACILITY NUMBER:
306006411
ADMINISTRATOR:LEE, YUNGFACILITY TYPE:
740
ADDRESS:1857 SHEDDON STREETTELEPHONE:
(818) 437-0477
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 6DATE:
05/08/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Hyo KimTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility did not provide care and supervision resulting in a resident eloping and sustaining an injury
INVESTIGATION FINDINGS:
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On May 8, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Hyo Kim was present and assisted on today's visit.

During the course of the investigation, LPA interviewed staff, interviewed a witness, reviewed and obtained documents for this complaint such as resident records. Regarding the allegation, facility did not provide care and supervision resulting in a resident eloping and sustaining an injury, the following has been concluded: It was alleged that the facility did not provide care and supervision resulting in Resident #1 (R1) eloping and sustaining an injury on May 5, 2026. LPA was unable to interview R1 for this complaint, due to R1 moving out of the facility on May 7, 2026. LPA conducted a records review for R1. LPA observed that R1 was discharged from a skilled nursing facility and was admitted into this facility on May 4, 2026.
CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20260506115738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUNNY VILLA
FACILITY NUMBER: 306006411
VISIT DATE: 05/08/2026
NARRATIVE
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Per R1's discharge summary report dated May 4, 2026, R1 had a diagnoses of vascular dementia and Parkinson's disease. It also states that R1 needs to be monitored for behaviors such as wandering, exit - seeking, and attempting to open doors. LPA conducted interviews with two staff who were present on May 5, 2026. Both staff interviewed confirmed that on May 5, 2026, at approximately 1:30 PM, R1 exited the facility without staff supervision. Both staff stated that they noticed R1 was missing approximately twenty minutes later at 1:50 PM and they began searching nearby areas. Both staff stated that they learned at approximately 2:50 PM, that R1 was transported to the hospital after a neighbor had witnessed R1 fell on the ground. Therefore, R1 was left without staff supervision for more than an hour, and was subsequently transported to the hospital after sustaining an unwitnessed fall. LPA conducted an interview with R1's Responsible Party, Witness #1 (W1). W1 confirmed that she was informed that R1 had went missing on May 5, 2026, and was transported to the hospital after sustaining an unwitnessed fall.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, facility did not provide care and supervision resulting in a resident eloping and sustaining an injury . The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D page. A civil penalty in the amount of $500.00 is also being assessed for absence of supervision. An exit interview was conducted with Administrator Hyo Kim. A copy of the report and appeal rights were provided at time of visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260506115738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY VILLA
FACILITY NUMBER: 306006411
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2026
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not evidenced by:
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The Administrator stated that she will conduct an in service training with all staff regarding resident supervision. The Administrator agreed to provide LPA proof of the in service training via email or fax by POC date.
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Based on interviews and records reviewed, the Licensee did not ensure that R1 was adequately supervised on May 5, 2026, despite R1 being diagnosed with dementia and having a behavioral history of wandering. This posed an immediate health, safety, and personal rights risk to persons 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3