565800429-5-31-2024-29-AS-DPEA-D5SSWK-20240531141428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800429
Report Date: 05/30/2024
Date Signed: 05/31/2024 12:48:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2023 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20230830164748

FACILITY NAME:	SUNRISE GUEST HOUSE		FACILITY NUMBER:	565800429
ADMINISTRATOR:	LAIGO-RAMOS, ANNABELLE L.		FACILITY TYPE:	740
ADDRESS:	2383 ELMDALE AVENUE		TELEPHONE:	(805) 520-1051
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 0	DATE:	05/30/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Annabelle Laigo-Ramos		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Insufficient staffing to meet residents needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with Licensee/Administrator and explained the reason for the visit. Entrance interview conducted.

On 08/30/2023, Community Care Licensing Division (CCLD) received the above complaint allegation. It was alleged that there is no staff coverage on Friday and Saturday from 12:00 p.m.- 3:00 p.m. and 6:30 p.m. – 7:00 a.m. Information was provided that Staff #1 (S1) is scheduled to work Fridays and Saturdays from 7:30 a.m. to Noon and 3:00 p.m. to 6:30 p.m. It was also alleged that this staff is left at the house with the residents at night and that there is no other staff coverage from noon to 3:00 p.m. and after 6:30 p.m.

Investigation into the allegation consist of interview with staff, and residents on 09/08/2023 and 01/24/2024. In addition, facility staffing schedule was reviewed with administrator on 01/24/2024.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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 29-AS-20230830164748

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE GUEST HOUSE	FACILITY NUMBER: 565800429
	VISIT DATE: 05/30/2024

NARRATIVE

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Interviews conducted revealed that S1 is scheduled to work Friday and Saturdays from 7:30 a.m. – 12:00 p.m. and 3:00 p.m. to 6:30 p.m. as a live in caregiver. Staff#2 (S2) and Staff #3 (S3) have a set schedule that they follow during the week and are live in staff from Sunday – Thursday. S2 works from 7:30 a.m.- 12:30 p.m. and from 5:00 p.m. to 8:00 p.m. S3 works from 7:00 a.m.- 9:00 a.m. and 12:00 p.m.- 6:00 p.m. Moreover, interviews with staff reflected that residents are usually resting between the hours of 12:00 p.m. to 3:00 p.m. and staff will use that time to take a break and have lunch. Staff further stated that residents have dinner from 4:30 p.m. to 5:30 p.m. and will go to bed between the hours of 6:30 p.m. – 7:00 p.m. Interviews further reflected that if residents needed assistance at any time, they would assist the residents given they are live in staff. Staff also stated that they will check on the residents prior to going to bed approximately between the hours of 9:00 p.m. and 10:00 p.m. Staff and administrator further stated that staff will wake up 3-4 times during the night to use the restroom and will periodically check on the residents. However, there was no documentation to support that the staff conducted nightly checks on residents.

Interviews conducted with two (2) out of the four (4) residents revealed that they are able to communicate their needs and expressed no concerns with staff failing to meet their needs. However, the two (2) other residents are not able to communicate and therefore, it was unable to determine if the staff were meeting the needs of those residents during the hours they are not working.

Moreover, facility staffing schedule (LIC500) dated 6/22/2023 reviewed on 01/24/2024, reflects additional staff coverage for the weekend. Although the staff are live in caregivers and administrator is on call when needed staff reported work schedule and actual staff schedule on record did not match. Staff schedule date 6/22/2023, reflects two staff on duty for the weekend. However, interviews with staff confirmed only one (1) weekend staff from Friday 7:00 a.m. to Sunday 7:00 a.m. Additionally, during the investigation, LPA discussed that the licensee should be in compliance with labor laws.

Based on the information gathered during the course of the investigation, the department has sufficient evidence to determine that there is insufficient staffing to meet the residents needs. Therefore, the above allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)
Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230830164748

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE GUEST HOUSE	FACILITY NUMBER: 565800429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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 is not met as evidenced by	1 2 3 4 5 6 7	Current there are no resident at the facility. Licensee stated she will be surrendering her license. Licensee agreed to submit a plan of correction by 5/31/2024.
	8 9 10 11 12 13 14	Based on interview conducted staff #1 reported being the only one staff on the weekends from 7:30am - 7am. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC9099 (FAS) - (06/04)

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