374603793-4-10-2024-08-AS-LTEZ-D4PPUB-20240426113712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603793
Report Date: 04/10/2024
Date Signed: 04/10/2024 05:26:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2020 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20201117145252

FACILITY NAME:	SUNRISE OF SABRE SPRINGS		FACILITY NUMBER:	374603793
ADMINISTRATOR:	KLEMP, SHAUNA LYNN		FACILITY TYPE:	740
ADDRESS:	12515 SPRINGHURST DR		TELEPHONE:	(858) 391-9160
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	0	CENSUS: 0	DATE:	04/10/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	N/A, Report Mailed to Licensee		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Licensee neglected to assist resident with eating.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior Complaint allegation. Since the facility closed on 03/15/2024 due to a change in ownership, the allegation finding was delivered to Licensee via USPS certified mail.

The Complainant alleged Licensee’s staff neglected to help Resident #1 (R1) with eating because R1 (who was diagnosed with Dementia) appeared to be very hungry and because R1 lost significant body weight while living at the facility. CCLD’s investigation involved an unannounced facility tour and welfare check on residents in care. The Department also reviewed pertinent care, medical, hospital, and hospice records, and interviewed relevant staff and outside sources.

[CONTINUED ON LIC 9099-C, 1 of 2]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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 08-AS-20201117145252

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNRISE OF SABRE SPRINGS	FACILITY NUMBER: 374603793
	VISIT DATE: 04/10/2024

NARRATIVE

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[CONTINUED FROM LIC 9099]

According to their LIC602 Physician’s Report (dated 04/13/2020) and facility care plan (dated 09/07/2020), R1 was diagnosed with Dementia but was able to eat independently. Interviews of facility staff and outside sources corroborated that R1 knew how to use dining utensils, was able to eat without prompting, and had a strong appetite for food as per their baseline condition. Facility date and time-stamped electronic care notes repeatedly showed that up until the last few weeks their life, R1 consistently finished 100% of the meals served to them. Hospital records, from a week before R1 passed away, reiterated that R1 was still able to “feed [themselves].”

According to facility and hospital records: On 11/07/2020, staff called 911 because R1 displayed pronounced lethargy and an episode of vomiting blood. At the hospital emergency room, R1’s blood sugar measured 471 mg/dL at 6:32 PM. (According to hospital records, a “normal” blood sugar range for R1 was supposed to be between 70 and 99 mg/dL.) R1 received insulin medication at the hospital. By 10:19 PM that same evening, R1’s measured blood sugar went down to 394 mg/dL. By 6:51 AM on 11/08/2020, R1’s blood sugar was at 260 mg/dL. Hospital physicians diagnosed R1 with hyperglycemia. One doctor wrote they believed R1 was diabetic (despite no prior documented history of such) due to R1’s blood glucose levels being “widely uncontrolled.” [Prior to this hospital trip, R1’s LIC602 and facility care plan did not mention them being diabetic or pre-diabetic. Also, interviews showed that facility staff and R1’s responsible person (RP) were unaware of R1’s body failing to regulate blood sugars.] Hospital physicians also diagnosed R1 with Stage 3 chronic kidney disease, toxic encephalopathy, and hyperosmolarity with hypernatremia. R1 discharged from the facility on 11/08/2020 under the concurrent care of a hospice agency.

According to the National Library of Medicine (NLM), which is maintained by the federal National Institutes of Health: Hyperosmolarity with hypernatremia is a common complication from poor management of diabetes. It is a condition in which a person’s blood is too concentrated with sodium, glucose, and other substances. This in turn draws water away from other organs, including the brain. Toxic encephalopathy indicates brain dysfunction caused by toxic exposure. According to an 01/23/2022 article published by the Cleveland Clinic: Insulin is a hormone which allows the body to convert glucose (i.e., sugar) to usable energy. Diabetic patients either do not produce insulin or cannot use it effectively. [CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20201117145252

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNRISE OF SABRE SPRINGS	FACILITY NUMBER: 374603793
	VISIT DATE: 04/10/2024

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2] When diabetes is not effectively managed, glucose builds up in the bloodstream instead of being transported to cells. To create needed energy, the body compensates by rapidly burning fat and muscle, which can cause unexplained weight loss despite outward strong appetite for food. Their kidneys can become damaged as they use additional energy trying to eliminate excess sugar from the blood. Vomiting and water loss are some symptoms of unmanaged high blood sugar.

Facility progress notes showed that R1 maintained stable body weight during an earlier period: They were 181 lbs. on 11/06/2019, 180 lbs. on 12/31/2019, 182 lbs. on 02/27/2020, and 189.6 lbs. on 03/30/2020. Thereafter, Licensee stopped routinely weighing R1. On 11/08/2020, the outside hospice agency independently weighed R1 at 143 lbs., as documented in its own admissions assessment. According to their official Death Certificate, R1 passed away on 11/14/2020 due to “Senile Degeneration of the Brain, Not Elsewhere Classified.” R1’s weight loss and/or nutrition were not listed as contributing factors to their death.

Based on records and interviews, a preponderance of evidence does not exist to show that R1 required staff assistance with eating, and that Licensee neglected to provide such help. The complaint allegation is therefore Unsubstantiated.

A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee via USPS certified mail.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

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