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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435201317
Report Date: 02/20/2024
Date Signed: 02/20/2024 03:32:39 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
08/10/2023 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230810125235
FACILITY NAME:SUNNY VIEW RETIREMENT COMMUNITYFACILITY NUMBER:
435201317
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
741
ADDRESS:22445 CUPERTINO ROADTELEPHONE:
(408) 454-5600
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:190CENSUS: 120DATE:
02/20/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: LVN Residential Manager, Fidel ManuelTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not ensure resident safety, resulting in resident sustaining an injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with LVN Residential Manager, Fidel Manuel and stated the purpose of the visit.

On 8/10/2023, the Department received a complaint regarding facility not ensuring resident’s safety which resulting in resident sustaining an injury. On 8/7/2023 at about 6am, resident (R1) was found in the bedroom with half his/her body hanging off of the bed and leaning on his/her right side. R1 was repositioned and per staff, R1 did not complain of pain. Around “lunch time” same day, R1 was sliding towards the edge of his/her wheelchair in the activity room. When staff repositioned R1 on the wheelchair, R1 sustained a skin tear on the right wrist. At that time, R1 complained of leg pain to the staff and facility sent R1 to the hospital around 1:45pm.

Continuation on LIC 9099-C, Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
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 3
Control Number 26-AS-20230810125235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNNY VIEW RETIREMENT COMMUNITY
FACILITY NUMBER: 435201317
VISIT DATE: 02/20/2024
NARRATIVE
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Page 2 of 3.
On 8/7/2023, from about 2am - 6am, R1 had 2 (two) unwitnessed falls in his/her room, where R1 was found on the floor or sliding off the bed. On 8/14/2023, the Department received an Incident Report dated 8/7/2023, stating at about 6:00am staff observed half of R1’s body hanging off the bed, leaning on the right side. R1 was repositioned in bed and R1 did not have any pain. On 8/21/2023, the Department received an addendum to the Incident Report for 8/7/2023 stating R1 was observed at about 2:00am on the floor next to his/her bed in a sitting position during safety check rounds. Staff did not observe any injury and 2 staff assisted R1 back to bed. Report stated staff did not document the incident and the facility conducted in-service training on 8/19/2023.

Based on record review of R1’s file, R1 has a history of falls which have been sustained before and after being admitted to the facility. Based on Physician’s Report dated 6/17/2022, R1’s other conditions were listed as “repeat falls” per physician’s notes. R1’s Services Plan dated 5/10/2023, R1 had a history of 9 falls within the year 2022 and episodes of increased confusion, hallucinations, and weakness. R1 requires daily dress/undressing, bathroom twice a week, routine bathroom assistance, and wheelchair escort. The Services Plan does not address R1’s fall-risk behaviors.

Based on interviews conducted on 8/16/2023 with 4 staff (S1-S4), 4 out of 4 staff stated R1 had a history of falls and needed 2 person assistance for Activities of Daily Living (ADL), which included bathing, dressing, and toileting. 4 out of 4 staff stated R1 needs bed rails to help assist with falls. Based on an interview with Resident Services Director (RSD) on 8/17/2023, R1 did not need fall prevention precautions but R1 would benefit from them. Per RSD, R1 used a half-bed rail and R1 is on 2-hour safety checks conducted by staff.

After the incident occurred on 8/7/2023, R1 was admitted to the hospital from 8/7/2023 through 8/11/2023. Based on R1’s hospital notes, the reports stated the hospital conducted X-rays of R1's knees and ankles. The impressions of the knee discovered a “comminuted distal femur fracture above the right knee prosthesis. The impression of the ankles were “chronic appearing and severe degenerative changes throughout the ankle. No gross fracture”. Per discussion of the hospital physicians, based R1's advance dementia and prior low level of function, surgery was not appropriate. Based on review of R1’s interdisciplinary Notes, R1’s responsible party updated facility of R1’s condition, stated R1 sustained a fracture in R1’s knee, R1 would not return to his/her normal baseline and R1 would become bed bound.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20230810125235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNNY VIEW RETIREMENT COMMUNITY
FACILITY NUMBER: 435201317
VISIT DATE: 02/20/2024
NARRATIVE
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Page 3 of 3.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with LVN Residential Manager, Fidel Manuel and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3