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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800429
Report Date: 06/20/2023
Date Signed: 06/20/2023 07:46:18 PM

Document Has Been Signed on 06/20/2023 07:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNRISE GUEST HOUSEFACILITY NUMBER:
565800429
ADMINISTRATOR:LAIGO-RAMOS, ANNABELLE L.FACILITY TYPE:
740
ADDRESS:2383 ELMDALE AVENUETELEPHONE:
(805) 520-1051
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 5DATE:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:05 PM
MET WITH:Annabelle RamosTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian generated a Case management - Deficiencies report to address deficiencies noted during the course of the complaint investigation of complaint control #29-AS-20230207120251. Following deficiencies were noted:

· On the night of 05/07/2022, S1 was asleep and R1 had no means or ability to summon assistance in the event of an emergency. R1’s room is located at the farthest point in the facility from the staff bedroom. R1 ultimately died from strangling in R1’s bed by getting their head caught between the bed and the bed rail. R1 called 9-1-1 but died before paramedics arrived. The licensee failed to ensure that staff were present in sufficient numbers and competent to provide services necessary to meet client needs at all times. During the week, 2 staff lived in the facility but only one staff was present on the weekends. On 05/07/2022, S1 worked over 16 hours (7:00am to 11:00pm) fell asleep and struggled to awaken to the emergency personnel on 05/07/2022 who were summoned by a 9-1-1 call generated by R1. S1 was not aware that R1 was experiencing an emergency.
· A Physician’s Report dated 05/04/2022, documented that R1’s ambulatory status had changed from non-ambulatory to bedridden. Facility did not have a bedridden fire clearance.
· Licensee/Administrator or assistant administrator did not reassess and update the reappraisal to reflect R1’s change of condition and needs.
· During the initial complaint visit on 02/08/2023, Licensee/administrator provided a copy of the death report and fax confirmation dated 05/09/2022 as proof of submission of R1’s death report. However, the completed death report did not accurately describe R1’s death and was not submitted within 24 hours as required by regulation.

The above deficiencies are cited from the California Code of Regulations, Title 22 and California Health and Safety Code. A $500 immediate civil penalty is assessed today. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2023 07:46 PM - It Cannot Be Edited


Created By: Zabel Chochian On 06/20/2023 at 06:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE GUEST HOUSE
FACILITY NUMBER: 565800429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/22/2023
Section Cited
CCR
87411(a)

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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:
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Licensee shall submit plan how they will ensure an adequate number of staff to meet the needs of the residents at all times. Submit plan and updated LIC 500 Personnel Summary Record to CCL by 6/22/2023.
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Based on interviews and record review, only one staff worked on the weekends for 6 non-ambulatory residents, which posed an immediate health and safety risk to residents in care.
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Request Denied
Type A
06/22/2023
Section Cited
CCR87202(a)(2)

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Fire Clearance:All facilities shall maintain a fire clearance approved by the city, county,or city and county fire department, or district providing fire protection service or the State Fire Marshal. Prior to accepting or retaining.. (2) Bedridden persons. This requirement is not met as evidence by:
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Licensee/Administrator stated currently there are no bedridden residents at this time. Licensee/Administrator stated she will submit plan how they will ensure compliance with this section cited in the future. Submit plan by 6/22/2023.
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Based on records review, licensee/administrator retained bedridden resident (R1) at the facility with-out bedridden fire clearance.
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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
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2023 07:46 PM - It Cannot Be Edited


Created By: Zabel Chochian On 06/20/2023 at 06:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE GUEST HOUSE
FACILITY NUMBER: 565800429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/27/2023
Section Cited
CCR
87463(a)(3)

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Reappraisals:(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. Significant changes shall include but not be limited to:(3) Any illness, injury, trauma....
This requirement is not met as evidenced by:
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Licensee shall submit a plan of how you will ensure Reappraisals are updated when residents have a change of condition. Submit to CCL by 6/27/2023.
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Based on record review, R1’s Reappraisal was not updated when R1 had a change of condition from non-ambulatory to bedridden, which posed a potential health and safety risk to residents in care.
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Request Denied
Type B
06/27/2023
Section Cited
CCR87211(a)(2)

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Reporting Requirements: Each licensee shall furnish to the licensing agency such reports.... Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents... within 24 hours..
This requirement is not met as evidence by:
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Licensee shall submit a plan on how they will ensure reporting requirement is met moving forward. Submit to CCL by 6/27/2023
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Based on record review, licensee/administrator did not accurately complete the death report and notify the department within 24hrs of R1’s death. This posed a potential health and safety risk to residents in care.
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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
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
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