445202756-5-10-2021-26-AS-KHOS-C2WJAS-20210511065312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 04/19/2021
Date Signed: 05/10/2021 09:49:33 AM

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
02/08/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210208143042

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; 132; 132	CENSUS: 92	DATE:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	03:43 PM
MET WITH:	Tami Ojwang		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility retains residents with prohibited health conditions

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ryker Heberle and Marybeth Donovan conducted a Tele-Visit due to COVID-19 Pandemic restrictions to deliver the complaint investigation finding. LPAs met with Tami Ojwang, General Manager.

Department opened a complaint via unannounced in person visit on 02/08/2021 regarding the above allegations. During the course of the investigation, LPAs visited the facility 4 times (2/8/2021, 2/11/2021, 2/19/2021, 3/19/2021), interviewed 18 residents and 16 staff, and reviewed 9 residents' records.

Continued in 9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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 4

Control Number 26-AS-20210208143042

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: 445202756
	VISIT DATE: 04/19/2021

NARRATIVE

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On 02/08/2021, LPAs visited the facility to investigate the medical care and condition of three residents (R5, R6, and R7) specified as not receiving adequate care. R5 was indicated as having a prohibitive health condition (pressure wounds). During visit, LPAs did not observe visible pressure wounds, nor any indication that the wound had been leaking pus. R5 was observed to be clean, and R5's room was observed to be tidy.

LPAs interviewed R5's family member (F1). F1 stated that his/her mother was on hospice and that both the facility and hospice nurses had been providing a satisfactory quality of care to R5, and that R5 had been visited regularly by hospice.

LPAs interviewed hospice agency on 03/11/2021. During the interview with the hospice nurse (HN) responsible for assisting R5, HN indicated that R5 had the pressure wound upon initiation onto hospice. Upon admission, pressure wounds had not exceeded stage 2. HN further stated that while the wound had been advancing since admission to hospice, it has never reached the point of becoming a prohibitive health condition. Hospice notes reviewed indicate that the resident has received regular care and wound treatment from hospice.

R5's wound care notes from hospice indicate that the pressure wound is stage 2.

LPAs reviewed the records of 8 additional residents at facility, including all that had been receiving wound treatment. 8 out of 8 records reviewed did not produce evidence of any residents having a prohibitive health condition.

The Department has investigated the complaint allegation listed. Based on observation, interviews, and review of records, The Department has found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted with Administrator Tami Ojwang and a copy of this report provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
02/08/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210208143042

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; 132; 132	CENSUS:	DATE:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	03:43 PM
MET WITH:	Tami Ojwang		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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9

Recidents are not receiving proper medical attention.

INVESTIGATION FINDINGS:

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2
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5
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13

Licensing Program Analysts (LPAs) Ryker Heberle and Marybeth Donovan conducted a Tele-Visit due to COVID-19 Pandemic restrictions to deliver the complaint investigation finding. LPAs met with Tami Ojwang, General Manager.

Department opened a complaint via tele-visit due to COVID-19 pandemic on 01/08/2021 regarding the above allegations. During the course of the investigation, LPAs visited the facility 4 times (2/8/2021, 2/11/2021, 2/19/2021, 3/19/2021), interviewed 18 residents and 16 staff, and reviewed 9 residents' records. Resident interviews and resident record review did not indicate that residents were not receiving proper medical attention.

Continued in 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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 4

Control Number 26-AS-20210208143042

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: 445202756
	VISIT DATE: 04/19/2021

NARRATIVE

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On 02/08/2021, LPAs visited the facility to investigate the medical care and condition of three residents (R5, R6, and R7) specified as not receiving adequate care. R5 was indicated as having a prohibitive health condition, R6 was reportedly not being moved, and R7 was indicated as having multiple falls. Food delivery and bathing allegations listed on complaint were investigated on 12/30/2021 and 01/06/2021 complaints respectively.

During visit, LPAs conducted an interview with R5. R5 stated that he/she was getting assistance from facility when requested. LPAs did not observe visible pressure wounds on R5, nor any indication that a wound had been leaking pus. R5 was observed to be clean, and R5's room was observed to be tidy. LPAs also interviewed R5's POA, who stated that he/she was satisfied with R5's quality of care. R5's hospice notes indicated that he/she does have a pressure wound, but it is not prohibitive and is treated routinely.

LPAs interviewed R6 and R7 on 02/08/2021. R6 was observed to be clean and did not have any observable characteristics indicating that they had not been being moved regularly. R6 is deaf and was unable to communicate verbally. R6 is under hospice. Hospice Nurse (HN) interviewed stated that they have no reason to suspect that R6 is not moved regularly. HN assists R6 with showers and has not seen any new injuries or signs of neglect. During interview with R7, LPAs observed resident room and did not note any trip hazards. During interview R7 stated that facility staff assist him timely. R7 stated that he hadn't fallen recently. Review of R7s needs and services plan and physician's report indicate that R7 does not require assistance with mobility, transferring, activities, or fall prevention.

The Department has investigated the above allegation. Based on observations, records review, 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 deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with Administrator. A copy of this report was provided via e-mail for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4