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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425525
Report Date: 03/10/2023
Date Signed: 03/10/2023 10:47:18 AM

Substantiated


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
04/06/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220406092659
FACILITY NAME:SUNNY ROSE GLENFACILITY NUMBER:
336425525
ADMINISTRATOR:SHANNON JOHNSONFACILITY TYPE:
740
ADDRESS:29620 BRADLEY RDTELEPHONE:
(951) 679-3355
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY:81CENSUS: 49DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Diana SalasTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility has pests (scabies).
Residents need a higher level of care
Facility is in disrepair
Facility is not clean
Facility is understaffed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations noted above. LPA met with Executive Director Diana Salasand discussed the details pertaining to the complaint.

Regarding the allegation Facility has pests (scabies). At time when LPA George conducted their visit to the facility on 4/13/22. While touring the memory care unit, LPA observed there to be three (3) residents with a visible rash. However, per the previous Administrator Shannon there were multiple residents and even some staff with a rash. LPA observed for the rash was located on their forearms, chest, neck and face (side of eye). Per Shannon no one was diagnosed with having scabies but a rash. LPA observed that the group activities in memory care had not been suspended as the residents were observed doing a craft at the time of the visit. In addition, a review of record srevealed that there was one resident R1 that was being treated for scabies as it was specifically noted as a diagnosed of scabies.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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 9
Control Number 18-AS-20220406092659
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: 03/10/2023
NARRATIVE
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 At the time of the 4/13/22 visit the information provided is a contradiction of what was reported versus what was observed. There was in fact one (1) resident that had a confirmed case of scabies. Therefore, the allegation of facility has pests is SUBSTANTIATED.

Allegation: Residents need a higher level of care.

LPA conducted interviews and a record review pertaining to the allegation of residents need a higher level of care. Based on information provided confirms that resident #2 R2 does require a higher level of care as they have a colostomy bag, that they were admitted to the facility with. R2 stated that they could provide the care for their colostomy bag and that an outside agency was to come and assist R2 as well. However, issue began when the outside agency didn’t come and help with maintenance of the colostomy bag nor did R2 knowing how to properly care for the bag. R2 was observed not knowing how to care for the colostomy bag there was an issue with leaks from the bag and the contents were all over the rails in the room as well as the carpet. The allegation of residents needs a higher level of care is SUBSTANTIATED.

Allegation: Facility is in disrepair

Regarding the facility being in disrepair, it was reported that the alarm system in the memory care unit, the key lock came off, and that the alarms go on for no reason. LPA was provided an invoice of the facility’s fire alarm system being serviced by the firefighters and alarm company from previous Administrator Shannon. Per the invoiced reviewed the alarm was last serviced in September 2021. In addition, during the tour LPA observed a small back refrigerator inside the medication room located in memory care unit that was frozen shut preventing anyone from being opened. It is unknown if there are specimen samples inside the refrigerator. Based on observation interview and record review the allegation of facility is in disrepair is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 18-AS-20220406092659
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: 03/10/2023
NARRATIVE
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Allegation: Facility is not clean

At the time of LPAs complaint visit on 4/13/22, the facility’s common areas were observed to be clean. Throughout the facility LPA observed for housekeeping to making residents beds with clean linen. LPA did not observe any stains on the walls, carpet or bedding. In addition, the facility was observed to be odor free. Additional observations made during the facility tour consists of: LPA observed a red colored bowl full of urine sitting inside of resident # 3 (R3)s night stand inside of their room. When LPA asked staff about the urine, they could not confirm how long the bowel of urine was sitting there or why it was even there. It is important to note that LPA did observe a urinal bottle for resident to use. Based on observation of the bowl of urine sitting inside resident’s bedroom for an unknown amount of time the allegation of facility is not clean is SUBSTANTIATED.

Facility is understaffed.

Regarding the allegation of facility is understaffed, Shannon said that the facility has struggled with staffing off and on since the beginning or right before the pandemic. Shannon states that the company does awesome things to encourage and boost morale to try to sustain the staff that they have gift cards pizza parties staff appreciation, but it has been an ongoing hurdle. LPA discussed what resources has the facility has utilized to assist with meeting their staffing needs. Shannon stated that posting the job on Indeed as well as utilizing a staff agency. Information provided states that the response is that if there is a concern and it is brought up staff are threatened with being fired. In addition, it was reported the Administrator Shannon is barely on the premises and when she is not the Med Techs are to be in charge and oversee the facility operation. This allegation was substantiated in a previous complaint # 18-AS-20220106115449 stating that the Administrator is not present on the premises a sufficient number of hours to manage facility. The allegation of facility is understaffed is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.


An exit interview was conducted and a copy of this report, 9099C, 9099D and appeal rights were provided to Executive Director Diana Salas.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 18-AS-20220406092659
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2023
Section Cited
HSC
1569.269(a)(5)
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1569.269 (a)(5)
ENUMERATED RIGHTS: SEVERABILITY
Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This regulation was not met as evidenced by: The facility has an ongoing infestation. This is an immediate Health and Safety risk to residents in care.
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Licensee is to have an infection control training. POC cleared at the time of the visit as the training was on 3/7/23.
Type B
03/10/2023
Section Cited
CCR
87621(a)(1)
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87621 Colostomy/Ileostomy
(a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a colostomy or ileostomy under the following circumstances: (1) If the resident is mentally and physically
capable of providing all routine care for his/her ostomy, and the physician has documented that the ostomy is
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The licensee agrees to relocate R1. There is no POC needed as R1 was reloacted on 4/25/22.
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completely healed.This regulation was not met as evidenced by: The resident was unable to care for their colostomy bag properly. In addition, there was not a skilled professional to provide care in the interim. As a result of in proper care resident’s bag would leak getting onto surfaces such as the rails, and carpet exposing others to biohazardous waste. This is a potential Health and Safety risk to residents in care.
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The licensee agrees to defrost the refrigerator and properly discard of any specimens found inside. The refrigerator will be discarded. POC corrected at the time of the visit at the refrigerator was replaced.
Type B
03/10/2023
Section Cited
CCR
87303(a)
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87303(a) Matientenace and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by: LPA observed during the facility tour that there was a small black refrigerator that was unable to be opened, that was used to store collected specimens. It was unknown if there were specimen inside of the frozen refrigerator. This poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 18-AS-20220406092659
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by: LPA observed during the facility tour that there was a red bowl full of urine in resident’s bedroom. This poses a potential health and safety risk to persons in care.
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The licensee agrees to replaced the bowls and encoruage resident to use the urinal and or the restroom. No POC is needed as the bowls were replaced May 2022. This was cleared at the time of LPAs visit.
Type B
03/24/2023
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
Based on observation, interview and record review the licensee did not ensure that there was adequate staffing on at leasing one occasion. This poses a potential health, safety and personal rights risk to residents in care.
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The licensee will develop a staffing plan which will include utilizing staff from the Sister facility to assist with providing adequate staffing at the facility. The licensee will submit proof by 5pm on the due date indicated.
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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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 9
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
04/06/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220406092659

FACILITY NAME:SUNNY ROSE GLENFACILITY NUMBER:
336425525
ADMINISTRATOR:SHANNON JOHNSONFACILITY TYPE:
740
ADDRESS:29620 BRADLEY RDTELEPHONE:
(951) 679-3355
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY:81CENSUS: 49DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility has rats
Resident care needs are not being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations noted above. LPA met with Administrator ____ and discussed the details pertaining to the complaint.

LPA conducted a tour of the interior and exterior of the facility. LPA did not observe any droppings or traps throughout the tour. However, LPA was informed by previous Administrator Shannon, that the exterminator did come out to the facility most recently as of ____. Shannon denied that the facility doesn’t have any rats or mice but was treated for bedbugs and rodents within the past few months. In addition, during conducted interviews the allegation was also denied as the individuals denied having seen any rats and or hearing about their being rats at the facility. Based on observation, interview and record review the allegation of facility has rats is UNSUBSTANTIATED.

Continued on 9099C*
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 18-AS-20220406092659
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: 03/10/2023
NARRATIVE
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Allegation: Resident care needs are not being met

LPA conducted interviews and was not able to corroborate the allegation as feedback provided was that needs are being met in the form of meals being provided, staff being responsive when call lights are pressed as well as getting assistance with ADLs as needed. Due to a lack of evidence the allegation of resident care needs are not being met cannot be corroborated. The allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to Executive Director Diana Salas.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 9
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
04/06/2022 and conducted by Evaluator Javina George
COMPLAINT CONTROL NUMBER: 18-AS-20220406092659

FACILITY NAME:SUNNY ROSE GLENFACILITY NUMBER:
336425525
ADMINISTRATOR:SHANNON JOHNSONFACILITY TYPE:
740
ADDRESS:29620 BRADLEY RDTELEPHONE:
(951) 679-3355
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY:81CENSUS: 49DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Diana SalasTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Residents are not provided clean linens
Facility does not have sufficient supplies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations noted above. LPA met with Administrator Executive Director Diana Salas and discussed the details pertaining to the complaint.

Allegation: Residents are not provided clean linens
LPA conducted a facility visit on 4/13/22. During a tour of the facility, LPA observed housekeeping cleaning resident bedrooms which included linen being changed, the dirty/used linen was being removed and put into a basket, and new linen was then placed on the bed. Interviews conducted were not able to corroborate the allegation. The allegation is UNFOUNDED.

Continued on 9099C*
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 18-AS-20220406092659
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: 03/10/2023
NARRATIVE
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Facility does not have sufficient supplies

LPA conducted a complaint visit on 4/13/22. LPA toured the kitchen and observed an appropriate amount of dish soap, and cleaners to clean the kitchen and dishes. LPA went to the supply room and saw an ample amount of PPE supplies (gowns, masks, gloves, hand sanitizer). LPA observed in the supply room attached to the laundry room to have an ample amount of surface cleaner, disinfectant wipes, carper extraction cleaner, cleanser, disinfectant spray and laundry additive. There is not sufficient evidence to corroborate the allegation of facility does not have supplies, the allegation is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the department had there dismissed the complaint.



An exit interview was conducted and a copy of this report was provided to Executive Director Diana Salas.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 9