361880661-4-29-2021-18-AS-JESL-C2XRL7-20210512130639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880661
Report Date: 04/29/2021
Date Signed: 04/29/2021 02:53:59 PM

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
11/13/2019 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20191113103713

FACILITY NAME:	SUNRISE VALLEY INC - KAMANA		FACILITY NUMBER:	361880661
ADMINISTRATOR:	TAMISIN, ABIGAIL N		FACILITY TYPE:	740
ADDRESS:	18752 KAMANA RD		TELEPHONE:	(760) 880-2227
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Licensee Khristine Smith		TIME COMPLETED:	09:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is not meeting residents bathing needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javina George called the facility for the purpose of delivering findings for the above allegation. LPA George met with and advised the purpose of visit. Below is a summary of the findings of the investigation:

The investigation consisted of interviews of various individual's and obtaining documentation.

Based on a review of information gathered from documentation, and conducted interviews. Information provided and confirmed that there is not a home health aide that comes to the facility to bathe R1. Therefore, it is the facility staff's responsibility to bathe/shower R1. A review of facility shower logs indicate that R1 went 6 days without being bathed on more than one occasion. Licensee Khristine stated that staff have forgotten to document showers on the log.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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 18-AS-20191113103713

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: SUNRISE VALLEY INC - KAMANA	FACILITY NUMBER: 361880661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2021 Section Cited CCR 87464(a)(4)	1 2 3 4 5 6 7	87464 Basic Services (a)The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community. (4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will train staff about their roles and review their job descriptions and review personal rights. A shower log will be completed daily for two weeks, beginning on 4/29/21. Licensee will submit the sign in sheet, and shower log to CCL by 5pm on the due date indicated.
	8 9 10 11 12 13 14	Based on observation, interviews, and record review, the licensee did not ensure that basic services were provided to at least 1 out of 6 residents for 6 out of 6 days. This poses a potential Health, Safety, or Personal Rights risk 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
	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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20191113103713

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: SUNRISE VALLEY INC - KAMANA	FACILITY NUMBER: 361880661
	VISIT DATE: 04/29/2021

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

The above allegation of staff not meeting residents bathing needs 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.

Based on the investigation conducted deficiencies were observed and cited according to California Code of Regulations, (Title 22, Division 6, Chapter 87464(a)(4) Basic Services will be cited on the attached LIC9099D.

An exit interview was conducted and a copy of this report, 9099D, and appeal rights were provided to Licensee Khristine Smith.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3