397002682-1-17-2023-27-AS-KHOS-CN8R5N-20230119114324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397002682
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:25:08 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, 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:	12:50 PM
MET WITH:	Expectacion Vierra		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not follow care plan
Neglect / Lack of Care Resulting in Death

INVESTIGATION FINDINGS:

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

On 1/17/23 at approximately 12:50pm 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 Expectacion 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.

Facility Staff Did Not Follow Care Plan
During the course of this investigation the Department reviewed a Memorandum dated 2/23/2020 from Expectacion Vierra to all facility staff stating that R1's diet should be a soft diet only due to missing front teeth and a regular soft diet should consist of "chopped meat!" Continued on LIC 9099C...

Substantiated

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)

Page: 1 of 3

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

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

Based on medical reports, Fire Department reports and staff interviews, R1 consumed meat that was not chopped on 3/15/22 which resulted in R1 choking on a hot dog therefore the allegation of Facility staff did not follow care plan is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Neglect / Lack of Care Resulting in Death
On 3/15/22, R1 choked on hot dog served to her by the facility and died shortly after. The Death Certificate for R1 states R1 died from Acute Hypoxic Respiratory Failure (for days), and the underlying cause is Cardiac Arrest (for days), and Alzheimer's Dementia (for years). The responsible parties for R1 stated they were told R1 choked on a hot dog which got caught in R1’s "airway. " R1 fell onto the floor, so staff was unable to perform the Heimlich Maneuver and they called 9-1-1. R1 was unresponsive and the Emergency Medical Technicians (EMT) were able to revive R1. R1 was taken to the hospital and died eight days later. A Hospital nurse told the responsible party for R1 that R1 arrived at the hospital without her teeth. Administrator Expecatcio Vierra stated a Memorandum document located in R1's file, written and signed by herself and dated 2/23/2020, states "Diet: Soft diet only due to missing front teeth. Regular Soft Diet: chopped meat!" This Memorandum was sent to all care staff and marked as Urgent. A St. Joseph's Medical Center Emergency Room doctor stated R1 was sick and in cardiac arrest when she arrived at the hospital. The paramedics had already removed the item from R1's throat and R1 was intubated at the hospital. R1's teeth/dentures would have been removed when she was intubated. Based on the records reviewed, and interviews conducted, the facility did not ensure that R1 was wearing dentures and/did not serve food suitable for soft diet therefore the allegation of Neglect / Lack of Care Resulting in Death is substantiated.

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in death of a resident. Failure to correct the deficiency may result in additional civil penalties. At the time of the complaint visit, the issuance of an Enhanced Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49 Appeal rights were provided. Exit interview conducted with Expecacio Vierra. Copy of the report was provided to the Administrator and appeal rights were received.

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)

Page: 2 of 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/18/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services ... Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Effective immediately, the Licensee agrees to lock the kitchen door until food is ready to eat so that any dietary modifications needed can be addressed before residents enter the dining room and to ensure that residents are attended to while they consume food. Licensee will email an attestation to maja.jensen@dss.ca.gov by the POC.
	8 9 10 11 12 13 14	Based on interviews with staff, medical personnel, responsible parties and record reviews the facility did not provide for soft food or "chopped meats" as indicated in the memorandum issued to all staff by the licensee. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
Type A 01/18/2023 Section Cited CCR 87405(h)(5)	1 2 3 4 5 6 7	Administrator - Qualifications and Duties The administrator shall have the responsibility to:... Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Effective immediately, the Licensee agrees to lock the kitchen door until food is ready to eat so that any dietary modifications needed can be addressed before residents enter the dining room and to ensure that residents are attended to while they consume food. Licensee will email an attestation to maja.jensen@dss.ca.gov by the POC.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed the Licensee was aware that R1 required a soft diet or chopped food and did not ensure the provision of such. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3