445202756-5-10-2021-26-AS-KHOS-C2WHN2-20210511062002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 03/16/2021
Date Signed: 05/10/2021 10:17:04 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
12/30/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201230115944

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: 99	DATE:	03/16/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Tami Ojwang		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility failed to provide adequate food service
Residents are being barricaded in their rooms

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 findings. LPAs met with Tami Ojwang, General Manager.

Between 01/07/2021 and 03/16/2021 4 site visits were conducted on 1/8/2021, 2/8/2021, 2/11/2021, and 2/19/2021. On 1/22/21 a virtual visit was conducted via FaceTime. In addition, telephone interviews were conducted. 16 residents, 13 staff, 3 family members and 4 medical professionals were interviewed.

Records obtained and reviewed included resident and staff rosters, staff schedules, resident assist logs, menus, room service meal count chart, daily specialized diet matrix, food purchase logs, resident medical records including hospice records, and records for residents with special dietary requirements.

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: 03/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021

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 5

Control Number 26-AS-20201230115944

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: 03/16/2021

NARRATIVE

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On 02/11/2021 at 3:49pm, LPAs interviewed resident (R9) and observed a Styrofoam box of food labeled with resident's room number. Box contained an uneaten piece of chicken. R9 requires a diet of semi-solid foods with thickened liquids as outlined in the service plan agreement and hospice care plan. The food observed was not prepared per R9’s dietary requirements.

On 2/11/2021, LPAs interviewed 3 residents. 3 out of 3 residents interviewed stated they or their spouse had special diets, but that special diets were not prepared per the resident's needs. Records review of meal prep records did not reflect R9’s required diet. The records confirmed that R13 has a nut food allergy.

On 02/19/2021, 3 kitchen staff S9-S11 interviewed stated that food was prepared per resident’s dietary restrictions.

LPAs reviewed a report from the Santa Cruz Public Health Department Report dated 1/7/2021. The report states that during site visit conducted on 1/6/2021, several resident rooms were blocked off by a barricade. The facility was trying to keep COVID positive wanderers in their rooms. Residents housed in the barricaded rooms were later moved to the memory care unit. Photograph confirmed a barricade at the entry of a resident room.

Staff confirmed residents' rooms were barricaded.

The Department has conducted an investigation of the above allegations. Based on LPAs’ 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: 03/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20201230115944

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: 03/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/17/2021 Section Cited CCR 87555(b)(7)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b)(7): Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility will develop a plan to audit the food services records of residents to ensure they are current in order to meet residents' needs. POC due date is 3/17/2021.
	8 9 10 11 12 13 14	Based on records review, interviews, and observation, meals provided did not match R9 and R13's modified diets perscriped by physicians' as outlined in their care plans. This posed an immediate risk to the personal rights of residents in care.	8 9 10 11 12 13 14
Type A 03/17/2021 Section Cited CCR 87705(l)(5)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (l)(5): Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Observed as corrected during site visit. Facility will conduct staff trainings on providing care to residents with dementia, to include residents who exhibt wandering behaviors. POC due date is 3/17/2021.
	8 9 10 11 12 13 14	Based on records review and public health reporting, barricades were errected in the facility to block doors of dementia residents. This posed an immediate risk to the personal rights of 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: 03/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
12/30/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201230115944

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: 99	DATE:	03/16/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Tami Ojwang		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility failed to meet the residents' needs

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 on 01/06/2021 regarding the above allegation. During the course of the investigation, LPAs visited the facility 3 times (2/8/2021, 2/11/2021, 2/19/2021) interviewed 16 residents and 13 staff, reviewed 9 residents records, food service records, and reviewed photographs of food items.

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: 03/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20201230115944

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: 03/16/2021

NARRATIVE

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10 out of 16 residents interviewed stated that they were given multiple options as to what they wanted to eat and that substitutions were available in the case that they did not want either option. 6 out of 10 were unable to answer the question.

Food service records note variety of foods provided with options available to the residents.
13 staff out of 13 interviewed in regards to food service stated that food service was prioritized during the COVID-19 outbreak and that all residents were served and assisted with meals as needed.

LPAs reviewed the record of R13. Meals provided to resident and depicted in photographs were in accordance with dietary restrictions outlined in physician's report and doctor's notes.

The Department has investigated the above allegation. Based on interviews conducted, records reviewed and photographs, 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 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: 03/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5