445202756-9-11-2024-26-AS-KHOS-D97GWP-20240917054241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 09/11/2024
Date Signed: 09/11/2024 02:09:53 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
06/19/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230619142154

FACILITY NAME:	SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	445202756
ADMINISTRATOR:	MCKIE, JAMES		FACILITY TYPE:	740
ADDRESS:	80 FRONT STREET		TELEPHONE:	(831) 459-8400
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	132	CENSUS: 102	DATE:	09/11/2024
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Candi Bolin		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff neglect resulted in the death of a resident in care.
Staff are not following medication orders.
Facility is not safeguaring resident's personal belongings.
Facility is not maintaining a comfortable temperature for residents in care.

INVESTIGATION FINDINGS:

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On 9/11/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced investigation visit to deliver the investigation findings. LPA met with Executive Director Candi Bolin and explained the purpose of the visit.

Regarding the allegation of staff neglect resulted in the death of a resident in care, reporting party (RP) stated that R1 died on May 28, 2023 after getting a UTI in April. Staff does not encourage them to drink water and the rooms are too hot. R1 was left unattended on May 19, 2023, left in chair with feet on the floor in clothes with dentures all night long. R1 was only a level one care at when R1 entered because R1 was independent had all his/her wits and used a walker and administered own medications and dressed himself/herself. After the UTI R1 couldn't do those things never bounced back very well so we increased R1s level of care. However, they did not provide the level of care that was assigned as neglecting R1 that evening.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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-20230619142154

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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 445202756
	VISIT DATE: 09/11/2024

NARRATIVE

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According to the same statement that RP provided, the facility did make a note about the occurrence on May 19, 2023, when they found R1 that way. They have banned the resident assistant that was supposed to help R1 that night.

Based on records review, the facility provided the LPA with Progress Notes. In these progress notes, the facility was already observing R1’s changes in conditions. A new assessment was done on April 27, 2023. In this assessment, it was noted that R1 is at risk for injury which may cause permanent disability or be life threatening. The following interventions/practices are recommended to enhance the safety of your family member. Reminders to use call system for needed assistance. Also in these progress notes from April 2023 – May 2023, it is noted in several entries that R1 has been eating less and less and has been experiencing pain and was being monitored continuously. R1 was entered into hospice on May 24, 2023.

Regarding the allegation of Staff are not following medication orders, RP observed two of the medication technicians did not follow the orders. One staff member (S1) brought a 5 mg Valium and called it a hydrochlorothiazide. Another medication technician (S2) brought a whole Vicodin when the orders were to crush it into applesauce, but S2 brought the entire pill.

Based on records review in the progress notes, on 05/23/2023 9:48AM (Late Entry) states that R1s family member (F1) gave R1 a Vicodin medication and is not on R1s med list. R1s MD was faxed, and a staff member (S3) is aware and R1 will be monitored for any allergic reactions or behavior changes. LPA was also able to obtain this report.

Regarding the allegation that Facility is not safeguarding resident's personal belongings, RP stated that there is also a thief there that stole from R1 in December when R1 first moved in, a very valuable diamond ring and then on R1s deathbed, gold chain with charms.

LPA spoke to the Executive Director (ED), and it was stated that the facility did an internal investigation and did not find any proof that a staff stole the valuables.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230619142154

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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 445202756
	VISIT DATE: 09/11/2024

NARRATIVE

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Regarding the allegation of Facility is not maintaining a comfortable temperature for residents in care, RP stated that they had to ask facility to put an air conditioner in and it took weeks even though RP offered to buy it. R1s room was 90° on Easter even though the thermostat was set on 50°.

During the interview, ED mentioned that the facility has not reached that temperature. While the rooms don’t have air conditioning system, the facility does have portable aircons which they can provide to residents if requested. According to RP, although it took quite some time, the facility did provide air-conditioning in the room.

Based on interviews & records review, the department has determined 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, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

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