430708612-9-29-2023-26-AS-RMAO-CWHW3K-20231011165605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708612
Report Date: 09/28/2023
Date Signed: 09/29/2023 10:42:04 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210504122012

FACILITY NAME:	SUNNYSIDE GARDENS		FACILITY NUMBER:	430708612
ADMINISTRATOR:	KAREN MANDAIR		FACILITY TYPE:	740
ADDRESS:	1025 CARSON DRIVE		TELEPHONE:	(408) 730-4070
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94086
CAPACITY:	84	CENSUS: 34	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Brisa Romero		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident has sustained multiple falls while in care due to neglect.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Steve Chang conducted an unlicensed complaint investigation visit to deliver the investigation findings and met with Business Office Director Brisa Romero (BOD).

On 05/04/2021, the Department received a complaint with an allegation that Resident has sustained multiple falls while in care due to neglect.

On 5/14/2021, an initial investigation visit was conducted. LPA toured the facility, and interviewed 5 staff (S1 -S5) and 4 residents (R1 - R4). Residents' physician reports and residents Care Plans were obtained.

On 5/17/2023, Administrator Karen Mandair was interviewed.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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 26-AS-20210504122012

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNNYSIDE GARDENS	FACILITY NUMBER: 430708612
	VISIT DATE: 09/28/2023

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

Resident has sustained multiple falls while in care due to neglect:

On 05/14/2021, LPA interviewed resident R1. R1 stated he/she was fine to stay in the facility. R1 stated he/she was able to get help from staff to get around in the facility whenever he/she asked for help. On the same day, LPA interviewed 3 residents (R2 - R4). 3 Out of 3 stated they got help from staff when they moved from bed, went to restroom or get around in the facility. R3 stated the facility staff reminded residents to ask for help to get around in the facility.

On 5/14/2021, LPA interviewed staff S1. S1 stated 6 residents were assigned as a group and each group was supervised by 1 caregiver; caregivers still help residents in different groups if needed. S1 stated the facility always reminded residents to ask for help whenever they wanted to move. S1 stated R1's hospice care nurse suggested to provide a device for R1 to prevent falls which the facility did not have. The facility communicated with the family member of R1, but R1's family member disagreed to purchase. S1 stated R1 needed help to move around, but sometimes R1 tried to move around by self. S1 denied staff neglected residents.

On the same day, LPA interviewed 4 staff, all of them stated they reminded residents to ask for help when residents wanted to move. All of them stated they always helped residents when residents wanted to move. All of them stated they never neglected residents needed help. 2 staff stated the number of caregivers were enough to provide care and supervision to residents. 2 staff stated R1 sometimes wanted to walk without staff help that caused R1 sustained falls.

On 5/14/2021, LPA toured the facility. LPA observed staff in memory care unit were readily to help residents. LPA observed staff helped residents to stand up from chairs, and assisted residents to walk around with walkers. LPA observed staff helped residents participated in the activities.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20210504122012

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNNYSIDE GARDENS	FACILITY NUMBER: 430708612
	VISIT DATE: 09/28/2023

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

On 5/17/2021, LPA interviewed Administrator (ADM). ADM stated R1 had a fall on 5/16/2021, and the facility started to conduct hourly check for R1. ADM stated the facility suggested R1's family member to purchase extra device for R1 to prevent R1's falls and to purchase extra service such as hiring extra private caregiver for R1, but R1's family refused. ADM stated he/she will discuss with R1's family member for updating R1's care plan. ADM stated if R1's family member disagrees with the new proposed care plan, the facility will suggest that R1 to move to a small facility such as 6 beds facility. ADM denied the facility staff neglected residents.

Reviewing R1's medical documents, R1 was non ambulatory, and had history falls; according two staff's statement that R1 sometimes would like to walk by self without staff's help; R1 recently had more falls, R1's care plan should be updated such as hiring an extra private caregiver.

Based on the observation and interviews conducted, 6 Out of 6 staff denied neglected residents. Residents were instructed to ask for help when they wanted to move. Facility to update care plan due to R1's frequent falls. Facility increased the frequency of checking for R1 due to R1's falls. The facility figured out the solution plan to help R1. Caregivers were observed to assist residents to stand up from chair, to move around, and to walk around with walkers. Staff were observed residents to participate in the activities. The facility staff did not neglect residents.

The Department has investigated the above allegation. Based on observation, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations cited under California Code of Regulations Title 22.

Exit interview conducted with BCD. The report was provided to BCD for signature. A copy of the report was provided to BCD.

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3