445202756-5-10-2021-26-AS-KHOS-C2WJRM-20210511071657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 04/19/2021
Date Signed: 05/10/2021 08:56:26 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
02/10/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210210162048

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:	03:47 PM
MET WITH:	Tami Ojwang		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff failed to clean resident’s room.
Staff failed to provide resident with clean bedding.
Staff left resident in wet clothing for extended amount of time.
Staff do not allow resident on hospice to have visitors.

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 02/11/2021 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

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: 1 of 3

Control Number 26-AS-20210210162048

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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During site visit conducted on 02/11/2021, LPAs investigated allegations that a resident (R1) had been living in unsanitary conditions, including a dirty room, unclean bedding, and wet clothing. LPAs were unable to observe resident, who had locked him/herself in the bathroom. Room and bedding appeared to be clean and odorless. LPAs observed a chair being removed from the resident's room and moved to facility dumpster. Chair had a faint odor of urine that became detectable from approximately 3 inches away with visible stains. LPAs returned to the facility on 02/19/21 to interview and observe R1. R1 appeared to be clean. R1 was temporarily placed in another room while facility replaced the carpet in R1's room with laminate. R1's temporary room was odorless, and appeared clean. R1's bed was observed to not contain any stains or traces of uncleanliness. R1 was unable to answer LPAs questions.
On 3/11/2021 LPA interviewed medical professional (MP4) responsible for caring for R1. MP4 stated that they have never observed R1's room or person to be unclean in a manner beyond what is normal nor reflecting neglect. MP4 stated that they have never detected an odor in R1's room, nor any stains on clothes or furniture. MP4 stated that R1 is resistant to care. MP4 further stated that R1 has incontinence.
LPAs interviewed 2 facility cleaning staff members on 3/19/2021. 2 of 2 housekeeping staff indicated that R1's room is cleaned once a week as indicated on cleaning staff schedule. Housekeeping staff further stated that stains on chair have existed for an undetermined but long time. 18 out of 18 residents were observed to be clean and well groomed. LPAs observed 15 resident rooms, all were noted to be clean and odorless.
LPAs interviewed 3 staff members; facility administrator (Admin), registered nurse (RN), and maintenance director (MD). RN and Admin stated that family members of hospice residents were allowed to visit once per week for one hour. RN and Admin deny any family members of hospice residents being denied entry to facility. Facility administrator provided LPAs with memo supplied to residents and resident family members stipulating visitation policy. RN was on duty on 2/7/2020 and denies that R1's clothing, diapers, or bedding were left soiled for extended period. RN stated that facility was aware of R1's incontinence and attend to R1 frequently. MD was interviewed in regards to carpet cleaning. MD stated that carpet cleaning was enacted whenever requested by housekeeping or care-giving staff. MD indicated that they were preparing to replace carpet in R1's room per family request.

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-20210210162048

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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LPAs interviewed 1 resident also on hospice, resident stated that his/her child (F1) was permitted to visit regularly. LPAs contacted F1, who was visiting that day. F1 stated that they have never been denied visitation whenever they requested it.
The Department has investigated the above allegations. Based on observations. interviews conducted, and records reviewed, the Department found that the above allegations are 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 allegation did or did not occur.

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