445202756-5-10-2021-26-AS-KHOS-C2WHWZ-20210511063421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 04/19/2021
Date Signed: 05/10/2021 10:12:19 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
01/06/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210106153906

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:	03:35 PM
MET WITH:	Tami Ojwang		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility has inadequate staffing to meet resident's needs.
Residents' care needs not being met.

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 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.

Continued in 9099C

Substantiated

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)

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Control Number 26-AS-20210106153906

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 01/09/2021, the Department provided a memorandum of understanding to the facility's temporary administrators Lauren Powell and Kim Golden, enabling them to officially request staffing assistance, as a large number of staff members were unable to attend their shifts due to the COVID-19 outbreak.

Staff scheduling sheets for the week of 01/04/2021 to 01/08/2021 acquired on 2/11/2021 and 3/19/2021 indicate that there was insufficient caregiving staff available to compensate for those that needed to call off. Staff interviews indicated that activities staff assisted with care giving duties, but activities staff staged a walk-out on 01/07/2021.

One interviewed staff member (S1) stated that he/she was the only person working on their floor at the time of the interview. No other staff members were observed by LPAs. S1 stated that residents positive with COVID-19 were not being bathed. Resident shower records do not indicate that staff signed off on showers being provided for residents. 2 other staff members and 1 medical professional interviewed also indicated that showers were unable to be completed timely.

Resident assist logs obtained on 01/15/2021 indicated that on the week of 01/04/2021 to 01/08/2021, there were multiple instances of residents pressing their alarms and not receiving a response for over 30 minutes.

The Department has conducted an investigation of the above allegations. Based on interviews, observations and record review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be
SUBSTANTIATED.

Deficiencies cited per the California Code of Regulations Title 22, see attached 9099D.

Report reviewed with Tami Ojwang, General Manager, and a copy of this report provided electronically with appeal rights 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)

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Control Number 26-AS-20210106153906

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/20/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General(a): Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility has hired additional staff via staffing agencies. Administrator agreed to submit staffing plan, including staff retention plan in case of another surge to ensure personnel to be sufficient in number at all times to CCL by POC due date
	8 9 10 11 12 13 14	Based on records review and interviews, facility did not have sufficient staffing to meet resident's needs during COVID-19 outbreak. This posed an immediate risk to the personal rights of residents in care.	8 9 10 11 12 13 14
Type A 04/20/2021 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services(f)(4): Personal assistance and care as needed by the resident... with those activities of daily living such as dressing, eating, bathing. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a plan to ensure residents are assisted timely with personal assistance & care to CCL by POC due date.
	8 9 10 11 12 13 14	Based on records review and interviews, facility was unable to provide assistance and showers in a timely manner. This posed an immediate risk to the personal rights of the residents in care.	8 9 10 11 12 13 14

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

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