445202292-10-27-2020-26-AS-KHOS-BVGNXP-20201118095127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202292
Report Date: 10/27/2020
Date Signed: 10/27/2020 02:59:26 PM

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
06/03/2020 and conducted by Evaluator Jackie Jin

COMPLAINT CONTROL NUMBER: 26-AS-20200603135403

FACILITY NAME:	SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	445202292
ADMINISTRATOR:	JAMES MCKIE		FACILITY TYPE:	740
ADDRESS:	80 FRONT STREET		TELEPHONE:	(831) 459-8400
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	132	CENSUS: 107	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Craig Cady		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff is not properly serving resident's food
Staff are not following physician's order as noted
Staff failed to keep a comfortable temperature for resident's room
Staff failed to ensure resident is properly nourished
Staff failed to provide proper reassessment to resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jackie Jin conducted a tele-visit due to COVID-19 health pandemic to deliver the findings to the above allegations. LPA met with Craig Cady, Health Services Director.

Between 06/11/2020-09/16/2020 seven staff members were interviewed. All staff stated meals are currently being delivered to the resident’s apartment due to shelter in place. Meals are served in a box meal and staff will assist with reheating food if needed. Staff was not aware of a time resident was served cold food.

On 09/16/2020 a Food Service staff was interviewed. Food Service staff stated the facility serves 3 meals and 2 snacks. Meals served consist of a carbohydrate, fruits, proteins, and vegetables. Residents with special diets are documented in the care alert chart. Meals are prepared with low fat ingredients. When available, the facility will order low fat or fat free ingredients to prepare the meals. Food Service staff stated R1 was able to order on the menu, however, staff may assist R1 with choosing a healthier option.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200603135403

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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 445202292
	VISIT DATE: 10/27/2020

NARRATIVE

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Food Service staff stated when the kitchen receives a care alert for R1 to be on mechanical soft diet, the food service staff mechanicalize R1’s food. Weekly menu for 04/13/2020-06/13/2020 was reviewed, and meals served consist of fruits, vegetables, carbohydrates, proteins, and dairy. Progress notes between 08/01/2019-03/19/2020 were reviewed and indicated that R1 did not touch his meal that was served only one time for dinner. It was noted on 03/18/2020, R1 was encouraged to drink water. Meal service delivery checklist was reviewed for May 2020 and June 2020, and it indicated that R1 was served breakfast, lunch, and dinner. Meal service delivery report was not reviewed for March 2020 and April 2020 because facility only keep records for 30 days. Dietary physician’s order and doctor’s order were reviewed. The dietary physician’s order dated 07/30/2019 indicated R1 is on a regular diet with low fat. Progress notes indicated on 05/08/2020 R1 had teeth discomfort, and a Care alert was made on 05/09/2020 for soft food. The physician ordered a mechanical soft diet on 05/19/2020.

Between 06/11/2020-07/20/2020 six staff were interviewed. All stated that residents have thermostats in their apartments to adjust the temperature, and direct care staff can assist with adjusting the temperature or open the window if needed. All staff were not aware of a time the resident’s apartment temperature was uncomfortable.

Between 06/11/2020-08/25/2020 three staff were interviewed. All staff stated when the facility receives a physician’s order, it is reviewed by the health services staff and implemented immediately. Residents are reassessed when they have a change of condition, and the physician and family are notified. All staff were not aware of a time the facility did not follow physician’s orders. Staff stated R1 had a change of condition, and the physician and family were notified. A care conference was held with the family regarding R1’s change of condition. R1 was taken to a doctor’s appointment to be evaluated.

Progress notes, physician communication notes, physician’s order, and weight record were reviewed. The review of doctor’s order dated 12/30/2019 noted that the doctor ordered monthly weight, and the review of weight record shows the facility was following the doctor’s order. Progress notes and physician’s communication notes indicated that between 03/11/2020-03/19/2020 and 04/02/2020-04/28/2020 R1 did not have a change of condition. On 04/28/2020 R1’s physician was contacted due to change in condition involving weight. On 04/30/2020 the facility had a care conference to discuss R1’s condition and updated care plan. A doctor’s appointment was set up by the family to have R1 be evaluated. R1 went to the doctor’s appointment and facility updated care alert based on new physician’s orders.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200603135403

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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 445202292
	VISIT DATE: 10/27/2020

NARRATIVE

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Between 07/17/2020-08/07/2020 six residents were interviewed. 5 out of 6 residents stated the food was warm when served to their apartment. One resident preferred their food served cold. All residents stated food served at the facility is healthy and nutritious. 5 out of 6 residents stated the temperature in their apartment is comfortable and can adjust the thermostat if needed. The other resident did not comment on the apartment temperature.

On 06/11/2020 and 08/27/2020 a tour of the facility was conducted via FaceTime. Common area temperature was maintained at 72 degrees Fahrenheit and resident apartment temperature was maintained between 60-70 degrees Fahrenheit. Some resident apartments were observed with portable air conditioners. During tour, a lunch service was observed. Boxed lunch meals were delivered to each residents’ apartment. Meals consist of a main course, two sides, soup, and salad. Kitchen area was observed with 2 days’ worth of perishables and 7 days’ worth of nonperishable.

This Department has investigated the above allegations. Based on interviews, observations, and record reviews, the Department has determined that the allegations are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with Craig Cady, Health Services Director and a copy of this report will be emailed Craig Cady, Health Services Director on 10/27/2020 for signature

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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