374603793-4-10-2024-08-AS-LTEZ-D4PPUA-20240426113712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603793
Report Date: 04/10/2024
Date Signed: 04/10/2024 05:27:15 PM

Substantiated

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 did not regularly observe/measure resident for changes in weight.

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 that Licensee’s staff did not regularly observe/measure Resident #1 (R1) for changes in their body weight (and R1 lost a significant amount of 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]

Substantiated

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 4

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]

Facility progress notes showed: R1 maintained stable body weight for a 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’s staff stopped routinely weighing R1. On 11/08/2020, an outside hospice agency independently weighed R1 at 143 lbs., as documented in its own admissions assessment. On 11/10/2020, R1’s family member alerted facility management to R1’s weight loss, and not the other way around. Management interview and facility progress notes did not show that facility staff were earlier cognizant of R1’s significant weight loss, or that Licensee’s staff reported it to either R1’s responsible person or R1’s primary care physician. According to R1’s LIC602 Physician’s Report and care plan, and corroborated by staff and outside source interviews, R1 continuously relied on staff for help with bathing and dressing during the complaint allegation time-period.

Per interview of facility management, Licensee ordinarily aimed to weigh each resident monthly, but this practice was stopped during the COVID-19 pandemic due to concerns about cross-contamination via shared medical equipment. According to the published COVID-19 guidance (active during the complaint period) from San Diego County’s public health agency and Provider Information Notices (PINs) from CCLD, Licensees were not advised to stop measuring residents’ weights. Rather, PINs provided Licensees guidance on how to disinfect shared instruments/equipment, such that they could continue to be used safely. Regulation 87466 required Licensee to “ensure that residents are regularly observed for changes,” to include “unusual weight gains and losses.” The COVID-19 pandemic did not waive this this requirement.

According to facility and hospital records: On 11/07/2020, facility staff sent R1 to a hospital emergency room due to lethargy and an episode of vomiting blood. While there, R1 was newly diagnosed with hyperglycemia. Hospital physicians identified that R1’s blood glucose levels were “widely uncontrolled” and that R1 was likely diabetic. [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.] 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 diabetes, weight loss, and nutrition were not listed as contributing factors to their death.

[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 4

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]

Based on records and interviews, a preponderance of evidence exists to show that Licensee, for a period during 2020, did not regularly observe/measure R1 for changes in their body weight. The Complaint allegation is therefore Substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 9099-D page). Since the facility had closed and ceased operations as of the date of deficiency issuance, no Plan of Correction was formed with Licensee.

A copy of this report, the LIC 9099-D, 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)

Page: 3 of 4

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/10/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…When changes such as unusual weight gains or losses…are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible person, if any.”	1 2 3 4 5 6 7	As of the date of deficiency issuance, R1 had already passed away and the facility had closed and ceased operations. Therefore, no Plan of Correction was formed with the Licensee.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 89 residents (R1) was regularly observed for changes in weight and that such changes were documented and brought to the attention of the resident’s physician and responsible person. This posed a potential health 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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

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