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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430708612
Report Date: 12/14/2024
Date Signed: 12/15/2024 06:13:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220427093207
FACILITY NAME:SUNNYSIDE GARDENSFACILITY NUMBER:
430708612
ADMINISTRATOR:KAREN MANDAIRFACILITY TYPE:
740
ADDRESS:1025 CARSON DRIVETELEPHONE:
(408) 730-4070
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:84CENSUS: 41DATE:
12/14/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Brisa RomeroTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff not trained in Medication Administration

Unqualified staff giving insulin injections and blood sugar tests
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 12/14/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the weekend manager on duty, Brisa Romero, who also held the role as the Assistant Executive Director at this time.
A brief interview was conducted with the facility representative Brisa Romero at this time.
Current census was 41 residents.
The purpose of this visit was to inform this facility, and its representative Brisa Romero, that an ongoing investigation had been completed and the following findings were being delivered at this time.
Based on interviews conducted during the course of this investigation, it was learned that facility staff designated as Medication Technicians (Med Techs) were trained with the duties and responsibilities to handle, dispense, and document the resident medications at all times. It was learned that these individuals received additional hours of training on an initial and ongoing basis.
It was learned that these Med Techs were allowed to assist residents with Blood Glucose Testing and Insulin Pen Dialing for Self Injection.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
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 6
Control Number 26-AS-20220427093207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SUNNYSIDE GARDENS
FACILITY NUMBER: 430708612
VISIT DATE: 12/14/2024
NARRATIVE
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These training procedures were outlined in the packet that was designated for facility staff training and medication assistance procedures submitted by the facility designated Administrator into CCL for review. These procedures and staff related tasks outlined and stated the following:

Insulin Pen Dialing for Self Injection on page 72
Hand resident the insulin pen, and ensure they have a secure grip secure
before letting go to avoid dropping. Be aware of exposed needle at all
times

Allow resident to self administer injection and have them hold pen in place
for 10 seconds

Blood Glucose Checks on page 74


Hand resident the blood glucose meter, and ensure they have a secure
grip secure before letting go to avoid dropping. Be aware of exposed
needle/lancet at all times

Watch resident pierce their finger and place blood onto test strip according
to manufacturer instructions

It was learned that facility staff designated as Med Techs had to be passed and checked off by an evaluator prior to being able to handle, dispense, and document the resident medications on their own. This was done so by the Competency Verifications for the same policies and procedures conducted on Pages 78, 80, and 81 of the Medication Assistance Procedures.
It was learned that facility staff designated as Med Techs were allowed to assist residents with Blood Glucose Check by using hand over hand techniques to assist with piercing their finger and placing the blood onto the test strips.
It was learned that facility staff designated as Med Techs were allowed to assist residents with Insulin Pen Dialing for Self Injection by using hand over hand techniques to assist with injections and holding the pen in place for 10 seconds.
Based on a review of the forms and documents, as well as interviews conducted, facility staff designated as Med Techs were allowed to conduct these types of assistance with hand over hand with facility residents
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220427093207

FACILITY NAME:SUNNYSIDE GARDENSFACILITY NUMBER:
430708612
ADMINISTRATOR:KAREN MANDAIRFACILITY TYPE:
740
ADDRESS:1025 CARSON DRIVETELEPHONE:
(408) 730-4070
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:84CENSUS: 41DATE:
12/14/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Brisa RomeroTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff not administering medications per doctor's orders
Medications are not secured
Residents personal information not safeguarded
Delayed Egress Door not operating properly
Qualified Administrator not on site to oversee the operation
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 12/14/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the weekend manager on duty, Brisa Romero, who also held the role as the Assistant Executive Director at this time.
A brief interview was conducted with the facility representative Brisa Romero at this time.
Current census was 41 residents.
The purpose of this visit was to inform this facility, and its representative Brisa Romero, that an ongoing investigation has been completed and the following findings were being delivered at this time.
Based on a tour of the facility that was conducted, it was observed that the main doors leading into the Memory Care Unit of this facility was functional and in good repair at this time.
It was learned that all of the resident files and documents were properly safeguarded at all times. Resident information that needed to be shredded would be placed in the appropriate bins which were not accessible to the residents, and their responsible parties, at this time.
It was learned that the facility designated Administrator, Karen Mandair, designated the Business Office
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20220427093207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SUNNYSIDE GARDENS
FACILITY NUMBER: 430708612
VISIT DATE: 12/14/2024
NARRATIVE
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Manager, Brisa Romero, who also held a current Administrator Certificate at this time.
Based on a tour of the facility that was conducted, it was learned that all resident medications were centrally stored in the Memory Care Unit at all times.
It was observed that resident medications that were to be dispensed on a daily basis were stored in a mobile cart. It was observed that this mobile cart was locked and made inaccessible to the residents at this time.
It was learned that overflow medications were stored in bins in a closet type until also found in the facility medication room.
It was learned that this medication room was locked at all times except in the case when facility staff, designated as Med Techs, were present to pour the medications and ready them for dispensing to the residents.
A review of the facility medication administration record (MAR) and dispensing log was conducted. It was observed that the medications were being dispensed and documented as prescribed by the responsible licensed medical professionals at this time.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20220427093207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SUNNYSIDE GARDENS
FACILITY NUMBER: 430708612
VISIT DATE: 12/14/2024
NARRATIVE
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requiring assistance with Blood Glucose Checks and Insulin Pen Dialing for Self-Injection without proper documented training.
It was learned that these techniques were not found to be present in the Medication Assistance Procedures at this time even though they were being conducted and performed by the Med Techs at this time.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated representative at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20220427093207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: SUNNYSIDE GARDENS
FACILITY NUMBER: 430708612
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2024
Section Cited
CCR
87465(a)(5)
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Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed.
This facility was found to be deficient as evidenced by facility staff designated as Med Techs were practicing hand over hand when
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The facility designated representative stated that all staff designated as Med Techs will be scheduled and trained, for no less than (2) hours in duration, on the topics of hand over hand techniques when assisting residents with Blood Glucose Checks and Insulin Pen Dialing for Self-Injection. A statement of
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assisting residents with Blood Glucose Checks and Insulin Pen Dialing for Self-Injection without proper documented training for these techniques posing an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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correction, along with documented proof of training, will be completed and submitted into CCL by the due date. Proof of training will include the name of the trainer, topics that were trained, and a list of the attendees.
Type A
12/21/2024
Section Cited
CCR
87208(a)(6)
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Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to
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The facility designated representative stated that the Program Description for this facility, specifically for Medication Assistance Procedures, will be updated to reflect the proper training for hand over hand techniques utilized by facility staff designated as Med Techs. A statement of correction, along with
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residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
Plan for training staff, as required by Section 87411(c).
This facility was found to be deficient as evidenced by facility staff designated as Med Techs were practicing hand over hand when assisting residents with Blood Glucose Checks and Insulin Pen Dialing for Self-Injection without proper documented updated training for these techniques posing an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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a copy of the updated Program Description, specifically for Medication Assistance Procedures, will be completed and submitted into CCL by the due date.
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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6