445202756-5-10-2021-26-AS-SYIP-C2VUS4-20210510154944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 05/06/2021
Date Signed: 05/10/2021 10:22:17 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
11/25/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201125130947

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: 95	DATE:	05/06/2021
		UNANNOUNCED	TIME BEGAN:	05:15 PM
MET WITH:	Tami Ojwang		TIME COMPLETED:	05:24 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care
Staff failed to ensure a resident was properly fed
Staff failed to ensure a resident consumed appropriate amount of fluids while in care
Staff failed to properly report an incident regarding a resident

INVESTIGATION FINDINGS:

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

Department opened a complaint via tele-visit due to COVID-19 pandemic on 12/07/2021 regarding the above allegations. During the course of the investigation, LPA 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 R1's resident records. 18 residents interviewed did not have knowledge of R1's care.

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: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

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-20201125130947

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: 05/06/2021

NARRATIVE

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Resident (R1) central to complaint had been moved to a separate facility on 8/6/2020, where he/she had since passed away on 12/26/2020. Licensing Program Analysts (LPAs) Ryker Heberle and Marybeth Donovan were unable to interview R1 before his/her passing; however R1 was interviewed during previous complaint investigation. LPAs consulted on R1's previous interviews dated 7/17/2020 and 7/29/2020 from prior complaint to obtain/gather pertinent information. During 7/17/20 interview R1 stated that he/she was served 3 hot meals a day while at the facility. During 7/29/2020 interview, R1 stated that he/she does not eat very much anymore.

LPAs reviewed resident's file from the time he/she had spent at the facility. Resident progress notes, physician notes, internal incident reports, and physician's orders indicate that the resident fell on 5/14. The fall did not lead to serious injury and was reported to resident's PCP and family, resident was discharged without update to care plan and was sent home from the ER that same day. R1's 602 (dated 7/2019) does not indicate the need for fall prevention protocols nor assistance with motor functions or transferrals.

Progress notes indicate multiple instances of R1 denying food. Physician's Order from 05/08/2020 indicates a request for the facility to measure resident's weight once per month. Resident records contained a weight tracking sheet that the facility had updated monthly. Upon weight loss, facility switched R1 to soft foods diet on 5/9/20 to address his/her trouble swallowing. Progress notes indicate that facility staff encouraged R1 to eat meals and drink water. Meal service delivery reports indicate that R1 was brought food 3 times a day prepared to the standards of doctor's order from 5/19/2020.

This Department has investigated the above allegations. Based on interviews and records review, 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.

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: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

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