336425525-8-19-2021-18-AS-KCLS-C66UK7-20210823153840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425525
Report Date: 08/19/2021
Date Signed: 08/19/2021 10:02:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

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 Christine Le

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200710142447

FACILITY NAME:	SUNNY ROSE GLEN		FACILITY NUMBER:	336425525
ADMINISTRATOR:	KAREN ROPER		FACILITY TYPE:	740
ADDRESS:	29620 BRADLEY RD		TELEPHONE:	(951) 679-3355
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92586
CAPACITY:	81	CENSUS: 50	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Shannon Johnson		TIME COMPLETED:	10:12 AM

ALLEGATION(S):

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Resident sustained a stage 3 pressure injury while in care
Facility staff did not seek medical attention in a timely manner
Resident sustained a fractured wrist while in care
Lack of supervision resulting in resident falling

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to deliver the finding of the above allegations. LPA met with Executive Director Shannon Johnson.

The investigation was conducted by the Department. The investigation consisted of records review and interviews with relevant parties. The first allegation indicates that due to neglect/lack of care and supervision Resident 1 (R1) sustained a stage 3 pressure injury while in care. During the investigation, the Department did not obtain evidence to substantiate neglect/lack of care and supervision. Facility staff immediately notified the doctor when the wound presented on or about 5/21/20. Staff communicated with the doctor and scheduled a tele-med visit on 5/28/20 so the doctor could assess the wound. Although the wound progressed to a stage 3, it was not because of neglect. The second allegation indicates that the facility staff did not seek medical attention for R1’s wound in a timely manner. During the investigation, the Department did not obtain evidence to substantiate neglect/lack of care and supervision. Facility staff notified R1’s doctor when the facility became aware of the wound on 5/21/20. Staff continued to communicate with the doctor

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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 18-AS-20200710142447

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
RIVERSIDE, CA 92507

FACILITY NAME: SUNNY ROSE GLEN	FACILITY NUMBER: 336425525
	VISIT DATE: 08/19/2021

NARRATIVE

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about the wound until hospice care began on 6/2/20. The third allegation indicates that due to neglect/lack of care and supervision R1 sustained a fractured wrist while in care. During the investigation, the Department did not obtain evidence to substantiate neglect/lack of care and supervision. Facility staff was present in the room when R1 fell. R1 was standing and stable with the walker when staff turned to write in R1’s chart. Staff did not anticipate R1 falling. The fall was not due to neglect by staff. The fourth allegation indicates that R1 fell because staff failed to properly supervise them. During the investigation, the Department did not obtain evidence to substantiate neglect/lack of care and supervision. Staff was present when R1 fell. R1 was not left unattended. R1 was stable and standing with assistance with his/her walker when staff stepped away to enter notes on R1’s chart. Staff did not anticipate R1 falling.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the Executive Director.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

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