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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880689
Report Date: 03/14/2022
Date Signed: 03/14/2022 10:46:49 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220309092643
FACILITY NAME:SUNRISE AT EASTVALEFACILITY NUMBER:
331880689
ADMINISTRATOR:MANIQUIS, ROXANNEFACILITY TYPE:
735
ADDRESS:7323 PRAIRIE ISLAND CIRTELEPHONE:
(909) 730-1781
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:4CENSUS: 3DATE:
03/14/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Aichiro Funtila, CaregiverTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Facility staff did not properly manage resident's medications.
INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to initiate the 10 day visit to investigate the above-mentioned complaint allegation.

Investigation consisted of review of the information received from the complainant, interview with the complainaint, interview with the facility administrator, interview with one (1) staff and review of the record for R1. LPA collected a copy of the centrally stored medication log for March 2022, New medication orders from an Urgent Care visit dated February 6, 2022, and receipts for the purchase of the over the counter medications ordered.

LPA learned the following information: It is alleged that five (5) of the client's medication bottles did not have labels that were provided at the time of leaving the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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 2
Control Number 56-AS-20220309092643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SUNRISE AT EASTVALE
FACILITY NUMBER: 331880689
VISIT DATE: 03/14/2022
NARRATIVE
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 Interviews revealed that the medications in question are over the counter medications. Review of the record revealed that the facility has retained physician's orders and receipts for the over the counter medication ordered. The medications are listed on the centrally stored medication log. R1 moved from the facility on 03/12/2022. LPA is unable to review the clients medication as they were signed out and received by R1's responsible party on 03/12/2022.

Based on the available information, there is not enough information to corroborate or refute the alleged violation. We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2