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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880661
Report Date: 04/29/2021
Date Signed: 04/29/2021 03:10:15 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
11/26/2019 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191126162628
FACILITY NAME:SUNRISE VALLEY INC - KAMANAFACILITY NUMBER:
361880661
ADMINISTRATOR:TAMISIN, ABIGAIL NFACILITY TYPE:
740
ADDRESS:18752 KAMANA RDTELEPHONE:
(760) 880-2227
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:6CENSUS: 5DATE:
04/29/2021
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Licensee Khristine Smith, Administrator Abigail TamisinTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Facility staff neglect resident resulting in bruises.
Facility staff failed to contact resident's family after incident resulting in injury (bruising).
Facility staff failed to seek timely medical care for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George called the facility for the purpose of delivering findings for the above allegation(s). LPA George met with Licensee Khristine Smith and Administrator Abigail Tamasin and advised the purpose of visit. Below is a summary of the findings of the investigation:

The investigation consisted of interviews with various individual's and obtaining documentation that includes: a review of the facility's complaint history, including resident and staff records.

Based on a review of information gathered from documentation, and conducted interviews. LPA George was able to corroborate the allegation. Per the facility's body map for R1 the bruises are noted, there is an entry dated in R1's log dated 11/11/19, staff admits that R1 was grabbed too tight to prevent a fall.
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: 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 4
Control Number 18-AS-20191126162628
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
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The above allegation of Facility staff neglect resident resulting in bruises, 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.

Allegation #2 Facility staff failed to contact resident's family after incident resulting in injury (bruising). Based on observation, Documentation, interviews and record review, LPA was able to corroborate the allegation. There was not any documentation provided to support the facility had notified R1's responsible party about the incident that occurred in November 2019. There was nothing noted in R1s log that the responsible party was notified. Additionally, the facility did not submit an LIC624 noting that the incident had occurred. The above allegation(s) of Facility staff failed to contact resident's family after incident resulting in injury (bruising) 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.

Allegation #3 Facility staff failed to seek timely medical care for residents .
Based on observation, interviews, documentation and record review the facility staff did not seek medical attention for the incident that occurred on 11/11/19 where R1 sustained bruising. There was not an LIC 624 submitted to the department regarding the injury resulting in bruising. There was also no documentation in R1s log of having been sent out or facility staff informing the home health agency about the bruising, and if any additional medical attention would be necessary. The allegation of Facility staff failed to seek timely medical care for residents 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 deficiencies were observed according to California Code of Regulations, (Title 22, Division 6, Chapter will be cited and 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 and Administrator Abigail Tamasin.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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: 2 of 4
Control Number 18-AS-20191126162628
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
05/21/2020
Section Cited
CCR
87211(a)(1)
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87211 Reporting requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

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Licensee will conduct an inservice on reporting requirements and documentation. Submit sign in sheet to CCL by 5pm on due date.
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This requirement was not met as evidenced by: Based on observation, interview and record review the licensee did not report the bruises at least 1 time. This poses a potential Health, Safety or Personal Rights risk to persons in care.
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Type B
05/07/2021
Section Cited
CCR
80065(f)(3)
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80065 Personnel requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
(3) Provision of client care and supervision, including communication.


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Licensee will conduct an inservice on effective communication and working as a team. Submit sign in sheet to CCL by 5pm on due date.
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This requirement was not met as evidenced by: Based on observation, interview and record review the licensee did not ensure that there was communication in regards to the resident and obtaining the bruises. This poses a potential Health, Safety or Personal Rights risk to persons 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: 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: 3 of 4
Control Number 18-AS-20191126162628
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
05/31/2021
Section Cited
CCR
80075(a)
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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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The licensee will conduct an in-service on knowing when to seek medical attention. Proof shall be submitted to the department by 5pm on the due date indicated.
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This requirement was not met as evidenced by: Based on observation, interview and record review the licensee did not ensure R1 was given medical attention after obtaining bruises on one occasion. This poses a potential Health, Safety or Personal Rights risk to persons 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: 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: 4 of 4