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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802274
Report Date: 10/02/2020
Date Signed: 07/16/2021 04:32:21 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2019 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20191211113922
FACILITY NAME:SUNRISE TERRACE RCFE IFACILITY NUMBER:
405802274
ADMINISTRATOR:SADORRA, HECTORFACILITY TYPE:
740
ADDRESS:1135 OCEANAIRE DRIVETELEPHONE:
(805) 903-2255
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: DATE:
10/02/2020
UNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Edwin Ingan/LicenseeTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident sustained fractures from falls.
Facility failed to report falls to residents responsible party.
Facility does not have adequate staffing.
Residents are not being cared for properly.
Hoyer lift is being used without proper staff training.
Facility is not kept clean and sanitary.
Resident assist transfers are not being preformed safely by staff.
INVESTIGATION FINDINGS:
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This is an amended report, delivered on-site on 07/16/2021 at 11:30am.
At 12:30pm on 10/02/2020, Licensing Program Analyst (LPA) Mark Jeffries conducted a subsequent complaint investigation visit for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Edwin Ingan, the facility administrator. During the investigation, LPA conducted staff interviews on 12/16/2019 from 8:30am – 3:00pm with A1, A2, and S1-S3, and conducted records review on 12/16/2019 and 10/14/2020.
As to the allegation of, “Resident sustained fractures from falls.” Licensing Program Analyst (LPA) Mark Jeffries conducted facility physical plant inspection, file review and interviews. In interviews 3 of 3 staff (S1-S3) and 2 of 2 administrators (A1 and A2) that worked at the facility during the 3 months and 2 days that R1 resided at this facility. S1, S2 and S3 all stated that they had not seen or heard of R1 having a fall any time during his stay at the facility.
CONTINUED on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
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 29-AS-20191211113922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274
VISIT DATE: 10/02/2020
NARRATIVE
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CONTINUED from LIC9099
S1, S2 and S3 noted that R1 had a single leg amputation and stated that they had never observed or heard of R1 falling from the bed, toilet or chair during R1’s time at the facility. A1 and A2 denied that R1 had a fall during R1’s time at the facility. The file review of the facility revealed there were no incident reports for R1 that indicated R1 had a fall while residing in the facility. Facility filed one incident report during R1’s stay on 12/02/2019 for “shortness of breath” that resulted in Emergency Room Visit and Hospital Admission. Medical Records received from French Hospital by fax on 10/15/2020 did not note any fracture. On 10/14/2019, LPA received an email from Sierra Vista Hospital stating, "Looking at the patient’s records he does not have any recent fractures and was not treated at the hospital for such." Based on interviews, file reviews, no incident report of falls and no medical documentation to support allegation of fractures, at this time there is not enough evidence to support that allegation that R1 sustained fractures from falls. Therefore, the allegation of, “Resident sustained fractures from falls.” is unsubstantiated, at this time.
As to the allegation of, “Facility failed to report falls to residents responsible party.” LPA conducted facility physical plant inspection, file review and interviews. In interviews of 3 of 3 staff and 2 of 2 administrators that worked the facility during the time (3 months and 2 days) that R1 resided at that facility. Three of 3 staff stated that they had not seen or heard of R1 having a fall any time during his stay at the facility. Three of 3 staff noted that R1 had a single leg amputation and stated that they had never observed or heard of R1 falling from the bed, toilet or chair during R1’s time at the facility. Two of 2 Administrators denied that R1 had a fall during R1’s time at the facility. In the file review of the facility there were no incident reports for R1 that indicated R1 had a fall at any time while residing in the facility. Based on interviews, file reviews, no incident report of falls, no evidence of a fall and insufficient evidence to show R1 fell at the facility, at this time there is not enough evidence to support that allegation that the facility failed to report. Therefore, the allegation of, “Facility failed to report falls to residents responsible party.” Is unsubstantiated, at this time.
As to the allegation of, “Facility does not have adequate staffing.” LPA conducted facility physical plant inspection, reviewed staff schedule and Personnel Report LIC500, and conducted interviews of staff and administrators. Facility schedule indicates that two staff were present between the hours of 7am and 7pm, and additionally a single staff is present between the hours of 7pm to 7am. The Personnel Report LIC500 indicates that two staff are present between the hours of 7am and 7pm, and additionally a single staff is present between the hours of 7pm to 7am. During the months of October 2019 to December 2019, the facility Census was 3 residents. The staff to resident ratio during R1’s stay was 2:3 during the hours of 7am to 7pm and the ratio of staff to residents during the overnight shift was 1:3. CONTINUED on LIC9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20191211113922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274
VISIT DATE: 10/02/2020
NARRATIVE
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CONTINUED from LIC99099-C When the LPA arrived at the facility unannounced to conduct the physical plant inspection related to this allegation there were two staff present for a single resident R2. Administrator Hector Sadorra stated that the facility has additional staff available from the licensee’s other facilities, who are associated to this facility and could help if needed. Administrator sated that there were no call offs in the last two months that were not filled in by additional staff. R2 was independently ambulatory and R3 required a two person assist in transferring. Licensee stated that additional staff who were cleared and available from mutually owned facility, near this facility were available to assist, if needed. During the investigation, there was insufficient evidence to prove a lack of staffing occurred. Therefore, the allegation of, “Facility does not have adequate staffing.” is unsubstantiated, at this time.

As to the allegation of, “Residents are not being cared for properly.” LPA conducted inspection of the facility physical plant, conducted file review and interviews. LPAs conducted a physical plant inspection and observed the facility to be clean, safe, and sanitary. LPA’s review of resident files indicated that all medications reviewed were given as prescribed. R1 received services from Home Health Care three times per week for catheter changes. Based on staff schedules reviewed, there were two or more staff present during daily shifts, and one staff present during the overnight shift, with additional staff on-call. S1, S2 and S3 indicated that efforts were made to encourage R1 to engage in daily activities, including board games, reading, television, puzzles, and walks (with wheelchair), however, R1 would decline and would refuse to engage in any activity. Based on the evidence obtained, there is not enough evidence to support the allegation of, “Residents are not being cared for properly.” Therefore, the allegation is unsubstantiated, at this time.

As to the allegation of, “Hoyer lift being used without proper staff training.” LPA conducted inspection of the facility physical plant, conducted file review and interviews. On 12/16/2019 at approximately 9:00am, LPA observed a Hoyer Lift in the backyard patio of the facility. LPA interviewed Administrator as to the current location of the Hoyer Lift. Administrator, Albert Gregorio, stated that, “it was outside because it was not being used.” LPA conducted a file review of R1s’ Physicians Report, Medical Records, Pre-Admissions Appraisal and Appraisals Needs and Services Plan. LPA observed in the Physicians Report that R1 needed transfer assistance. In addition, it was also noted that a mechanical assistance could be used, "if needed." LPA did not observe orders to specifically use a Hoyer lift in R1's Physicians Report. S1, S2 and S3 interviewed indicated that a single person lift for R1 was sufficient to meet R1's needs and the mechanical lift was not needed. All facility employees associated to this facility had received CONTINUED on LIC99099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20191211113922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274
VISIT DATE: 10/02/2020
NARRATIVE
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CONTINUED from LIC9099-C Transfers/Mechanical lift/restraint training on 04/14/2018 according to facility staff training records and S1-S4 had completed Postural Support, Restricted Health and Hospice Care Training on 03/19/2019 according to facility staff training records. There is not enough evidence to support the allegation of, “Hoyer lift is being used without proper staff training.” Therefore, the allegation is unsubstantiated, at this time.
As to the allegation of, “Facility is not kept clean and sanitary.” LPA conducted a physical plant inspection of facility pertaining to the allegation. At the time of the inspection, LPA observed the facility to be clean and free of debris. LPA observed dishes, cups and water bottles to be clean and free of visual contaminants. On 12/16/2019, at 9:45am, LPA did note a smell of ammonia between the bathroom and bedroom in the hallway just after the morning resident care had finished. LPA interviewed a credible witness who visited the facility on multiple occasions and noted that the facility appeared clean and sanitary with no noticeable smells present. At this time there is not enough evidence to support the allegation of, “Facility is not kept clean and sanitary.” Therefore, the allegation is unsubstantiated, at this time. As to the allegation of, “Resident assist transfers are not being performed safely by staff.” LPA conducted a physical plant inspection, conducted interviews, reviewed resident files, reviewed facility incident reports, and reviewed staff training records. Based on R1’s physician’s report, pre-admissions appraisal and Appraisals Needs and Services plan, R1 was non-ambulatory and required assistance to meet R1’s daily needs. R1s’ Physicians Report stated that R1 needed transfer assistance. In addition, it was also noted that a mechanical assistance could be used, "if needed." LPA did not observe orders to specifically use a Hoyer lift. Staff training records reviewed, revealed all staff were current on their annual training requirements, which included training on safe transfers completed on 02/23/2019. All facility employees associated to this facility had received Transfers/Mechanical lift/restraint training on 04/14/2018 according to facility staff training records and S1-S4 had completed Postural Support, Restricted Health and Hospice Care Training on 03/19/2019 according to facility staff training records. There was not sufficient evidence to support that the allegation of, “Resident assist transfers are not being performed safely by staff.” Therefore, the allegation is unsubstantiated, at this time.
As to the allegation of, “Resident assist transfers are not being performed safely by staff.” LPA conducted a physical plant inspection, conducted interviews, reviewed resident files, reviewed facility incident reports, and reviewed staff training records. Based on R1’s physician’s report, pre-admissions appraisal and Appraisals Needs and Services plan, R1 was non-ambulatory and required assistance to meet R1’s daily needs. R1s’ Physicians Report stated that R1 needed transfer assistance. In addition, it was also noted that a mechanical assistance could be used, "if needed." LPA did not observe orders to specifically use a Hoyer lift. Staff training records reviewed, revealed all staff were current on their annual training requirements, which included training on safe transfers completed on 02/23/2019. All facility employees associated to this facility had received Transfers/Mechanical lift/restraint training on 04/14/2018 according to facility staff training records and S1-S4 had completed Postural Support, Restricted Health and Hospice Care Training on 03/19/2019 according to facility staff training records. There was not sufficient evidence to support that the allegation of, “Resident assist transfers are not being performed safely by staff.” Therefore, the allegation is unsubstantiated, at this time.
Exit interview conducted, Report Emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4