397002682-1-17-2023-27-AS-KHOS-CN8R5P-20230119114324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397002682
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:33:01 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2022 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20221027085402

FACILITY NAME:	SUNNY PLACE OF STOCKTON		FACILITY NUMBER:	397002682
ADMINISTRATOR:	EXPECTACIO VIERRA		FACILITY TYPE:	740
ADDRESS:	807 WEST SWAIN ROAD		TELEPHONE:	(209) 956-8677
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	18	CENSUS: 14	DATE:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Expectacion Vierra		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility failed to provide DNR to EMT

INVESTIGATION FINDINGS:

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On 1/17/23 at approximately 01:30 PM Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings for a complaint investigation in to the above listed allegations. LPA Maja Jensen met with Administrator Expectation Vierra and explained the purpose of today's visit.

During the course of the investigation, the Department reviewed the full file for resident 1 (R1) as provided by Administrator Expecatcion Vierra, the death certificate for R1, The American Medical Response (AMR) report, medical records and Fire Department records. The Department also interviewed 2 family members of R1, 3 residents of the facility, the Administrator and 4 staff.

A review of the facility file for Resident 1 (R1) shows a Physician Orders for Life-sustaining Treatment (POLST) dated 12/31/2018 which states do not attempt to
resuscitate, and selective treatment only and another POLST dated 2/20/2020 which states attempt resuscitation/CPR and full medical treatment. Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221027085402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNNY PLACE OF STOCKTON	FACILITY NUMBER: 397002682
	VISIT DATE: 01/17/2023

NARRATIVE

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Based on interviews conducted and medical records reviewed R1 was the recipient of resuscitation efforts and or CPR and received full medical treatment while hospitalized which does not conflict with the POLST. In addition there is no evidence to indicate that the POST was given to the Emergency Medical Team and also no evidence to indicate it was withheld therefore the allegation of the facility failed to provide DNR to EMT is unsubstantiated.

An exit interview was conducted and a copy of this report and appeal rights was provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

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