405802275-6-28-2024-29-AS-KBUY-D7NPCM-20240730111209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802275
Report Date: 06/28/2024
Date Signed: 06/28/2024 11:45:32 AM

Substantiated

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
10/30/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20231030143848

FACILITY NAME:	SUNRISE TERRACE RCFE III		FACILITY NUMBER:	405802275
ADMINISTRATOR:	INGAN, ZENAIDA		FACILITY TYPE:	740
ADDRESS:	1015 SAN ADRIANO STREET		TELEPHONE:	(805) 544-2883
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 4	DATE:	06/28/2024
		UNANNOUNCED	TIME BEGAN:	11:51 AM
MET WITH:	Licencee - Edwin Ingan		TIME COMPLETED:	01:52 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not refill resident’s medication prescription in a timely manner causing resident to get a seizure.

INVESTIGATION FINDINGS:

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

On 06/28/2024, at 11:50am, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to deliver the finial finding to the two allegations to this complaint. LPA met with Licensee, Edwin Ingan, announced who he is and the reason for the visit.

As to the allegation of, “Staff did not refill resident’s medication prescription in a timely manner causing resident to get a seizure.” It was alleged that, facility failed to order Resident 1’s (R1) medication leading to a 4-day lapse in medication administration of specific medication and ultimately resulting in R1 having a seizure and hospitalization. It was discovered through documentation and interviews on 10/31/23 with Administrator Edwin Ingan, who stated that, medications in question were not in stock at primary pharmacy. Administrator stated that he was “working to fill the medication with the pharmacy”. Administrator also stated that R1 missed 4 days of medication in question and was hospitalized due to seizure.
CONTINUED on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

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 29-AS-20231030143848

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 III	FACILITY NUMBER: 405802275
	VISIT DATE: 06/28/2024

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

Administrator stated that the medication in question of which R1 had missed for 4 days, was to address seizures. Administrator stated that he notified R1’s representative after R1 had the seizure and was hospitalization occurred on 10/27/2023. LPA Jeffries collected and reviewed Serious Incident Report dated 10/27/23 from facility reporting R1 seizure, UTI, hospitalization, and note indication “BE SURE MEDICATIONS ARE FILLED IN TIMELY MANNER. NOTIFY POA, DOCTOR, ADMINISTRATOR …” LPA reviewed Facility Centrally Stored Medication Records (CSMR) for R1 and noted that the medication in question was filled on 10/27/2023 after R1 had gone to the hospital due to seizure. Based on documentation, interviews, medical records and admission, there is enough evidence to support the allegation of, “Staff did not refill resident’s medication prescription in a timely manner causing resident to get a seizure.” and is substantiated at this time.

Administrator was informed that the case will be reviewed and it is possible additional civil penalties could assessed based on Health and Safety Code 1569.49(f).

Exit interview, report read, citation and fine issued, appeal rights and report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20231030143848

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 III	FACILITY NUMBER: 405802275
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/01/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical ... shall be developed by each facility. The plan shall encourage routine medical ... provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging,	1 2 3 4 5 6 7	Licensee agrees to a comprehensive 2-4 hour training corse of their choice on medications for all staff associated to this facility. Plan for completion and schedule should be emailed to LPA no later than 07/01/2024 by end of busniess day. (mark.jeffries@dss.ca.gov)
	8 9 10 11 12 13 14	for medical... appropriate to the conditions and needs of residents. This requirement was not met by evidence of admission of medication error resulting in R1 seizure and hospitalization, which put the resident in iminate danger	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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
10/30/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20231030143848

FACILITY NAME:	SUNRISE TERRACE RCFE III		FACILITY NUMBER:	405802275
ADMINISTRATOR:	INGAN, ZENAIDA		FACILITY TYPE:	740
ADDRESS:	1015 SAN ADRIANO STREET		TELEPHONE:	(805) 544-2883
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 5	DATE:	06/28/2024
		UNANNOUNCED	TIME BEGAN:	11:51 AM
MET WITH:	Licencee - Edwin Ingan		TIME COMPLETED:	01:52 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff left resident in soiled diapers for an extended period of time resulting in a UTI.

INVESTIGATION FINDINGS:

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

As to the allegation of, “Staff left resident in soiled diapers for an extended period of time resulting in a UTI.” It was alleged that R1 suffered a Urinary Tract Infection (UTI) as a result of staff not changing R1. It was discovered through interviews, documentation, and observations, that on 10/31/2024, LPA Jeffries conducted interviews with R2, R3, R4, and R5, who all stated that they had no issues with the care at this facility. R2-R5 all stated that they have never been left unassisted when needing assistance at this facility. On 10/31/2023, LPA Jeffries interviewed Staff 1 (S1) and S2. Both staff stated that residents are monitored constantly throughout the day and checked on every 30 minutes during the over night shift. S1 and S2 both deny leaving any Resident in soiled garments. On 10/31/2024 LPA Jeffries interviewed Licensee who stated there were no staff call offs during the months of September and October of 2023. LPA reviewed facility staff training records and all staff are current in regulated training hours. At this time there is not enough evidence to support the allegation of, “Staff left resident in soiled diapers for an extended period of time resulting in a UTI.” and is unsubstantiated at this time.
Exit interview, report read and report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4