<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425525
Report Date: 03/14/2022
Date Signed: 03/14/2022 10:38:10 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
01/06/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220106115449
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: 51DATE:
03/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shannon Johnson, Executive DirectorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's call light is not functioning.
Administrator not present on the premises a sufficient number of hours to manage facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to deliver findings for the allegation(s) listed above. LPA met with Shannon Johnson and explained the purpose of the visit as well as the elements of the allegation(s). The allegation was investigated by the department. The investigation consisted of observation interviews and record review.
Resident's call light is not functioning.
LPA discussed the allegation and conducted interviews. It was confirmed that the call lights were not working. It is unknown how long the call lights had been in operable. Per Business Office Manager, Leticia the facility staff had increased undocumented rounds to walk around and see if any of the lights were on, which is located on the outside above the resident bedroom doors. Leticia stated that the alert or page was not being sent to main hub, but the lights were functioning. Leticia also stated that she had placed a call to the company after the facility’s maintenance Director was unable to repair the system due to it being on an older model. Due to staff confirming the call system being broken the allegation of Resident's call light is not functioning is SUBSTANTIATED.

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: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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 5
Control Number 18-AS-20220106115449
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: 03/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator not present on the premises a sufficient number of hours to manage facility.

At the time of LPAs visit on 1/14/22, Administrator Shannon Johnson was unavailable at the time of LPAs visit. Additionally, the facility currently has an ad on job search engines for an Executive Director position. The administrator is experiencing medical challenges that are prohibiting for her from physically being at the facility, which in turn is preventing her from being able to manage the facility appropriately. LPA was able to speak with administrator via telephone after LPAs visit and was informed that Business Office Manager is in charge in administrator’s absence. There was no job description available to review, nor the LIC308-Designation of Facility Responsibility Shannon stated that she is also available via telephone. The allegation of Administrator not present on the premises a sufficient number of hours to manage facility is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, 9099D and appeal rights were provided to Shannon Johnson.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
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: 3 of 5
Control Number 18-AS-20220106115449
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: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
Section Cited
CCR
87303(1)(B)
1
2
3
4
5
6
7
87303 Maintenance and Operation
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
This requirement is not met as evidenced by: the signal system not transmitting an auditory signal. Staff had to increase their rounds to walk around and see if the light was on above each resident room. This poses a potential health safety or personal rights risk to persons in care.


1
2
3
4
5
6
7
The licensee agrees to have the call system repaired as soon as westcom is able to complete the request. The POC has already been completed. Verified during 3/10/22 visit and invoice received on 2/15/22.
Type B
03/29/2022
Section Cited
CCR
87405(a)
1
2
3
4
5
6
7
87405 (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section...

1
2
3
4
5
6
7
Agreed to complete LIC 308 and to hire additional help…
As of 3/7/22 the posting is no longer available, as Shannon returned to work on 3/2/22.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: the licensee did not have an administrator or designee available at least 1 out of 1 times to administer the facility. This poses a potential health, safety a or personal rights risks to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/06/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220106115449

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: 51DATE:
03/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shannon Johnson Executive DirectorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not wearing masks.
Facility is prohibiting visitors due to COVID-19.
Facility is not offering engaging activities.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to deliver findings for the allegation(s) listed above. LPA met with Shannon Johnson and explained the purpose of the visit as well as the elements of the allegation(s). The allegation was investigated by the department. The investigation consisted of observation interviews and record review.

Staff not wearing masks.
LPA conducted a visit to the facility on 1/14/22. During the time of LPAs visit (8:45am-10:35am), all staff were observed wearing the appropriate facial coverings (surgical masks, N95masks). Interviews conducted with various staff; all staff denied seeing staff on duty not wearing the appropriate facial covering and denied that they themselves did not wear masks while throughout their shifts. The facility supplies masks for those that need one. They can be found at the front desk, wellness office, and kitchen. There was not enough evidence to support the allegation of staff not wearing masks therefore the allegation is UNSUBSTANTIATED.
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: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220106115449
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: 03/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility is prohibiting visitors due to COVID-19.

At the time of LPAs 1/14/22 visit, the facility did have four confirmed positive covid cases with other test results pending, and was not permitting indoor visitation other than authorized representatives, essential visitors, or on a special case by case basis. The facility was waiting for further direction from CDPH on how to proceed, as the four cases were considered an outbreak. The front door was locked, however there were instructions posted on the door to call the main number or to ring the doorbell, which is the same protocol for after business hours. During an interview with Administrator Shannon Johnson. Shannon stated the front doors being locked are apart of the facility’s mitigation plan. The facility has a lot of traffic in and out of the building, locking the front door was way of ensuring that everyone that stepped foot inside the facility was properly screened, which would also assist with mitigating the spread of the virus. On LPAs 3/14/22 visit there is a sign informing visitors that the doors are unlocked during business hours. The allegation of Facility is prohibiting visitors due to COVID-19 is UNSUBSTANTIATED.

Facility is not offering engaging activities.
LPA conducted a visit on 1/14/22, LPA reviewed the resident activities calendars. On 1/14/22 The activities calendar indicated that 9am-morning walk. 10am-patio social, 1:30pm-bingo and 3pm-an afternoon walk. At 917am, LPA observed that there were various residents playing cards inside, some residents were still eating breakfast, and others were waiting to be covid tested. At 10:25am LPA observed 9 residents sitting under the gazebo in the courtyard talking, nodding their heads and some laughing, one resident was dancing, and another was briskly walking around the courtyard. During an interview with administrator she disclosed that the Activities Director resigned from their position, and that the caregivers are temporarily doing the activities and that the supplies are provided. Based on observation and interviews the allegation of Facility is not offering engaging activities is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.

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

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5