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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801625
Report Date: 11/03/2021
Date Signed: 11/03/2021 05:15:27 PM

Unsubstantiated


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
10/26/2021 and conducted by Evaluator Kasandra Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20211026150433
FACILITY NAME:SUNRISE MANOR, LLCFACILITY NUMBER:
565801625
ADMINISTRATOR:JULIANA ANOSFACILITY TYPE:
735
ADDRESS:441 WEST CHANNEL ISLAND BLVDTELEPHONE:
(805) 240-7600
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:60CENSUS: 55DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Juliana AnosTIME COMPLETED:
01:06 PM
ALLEGATION(S):
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Resident attacked another Resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10 day complaint inspection at the facility today regarding the above allegation. The LPA met with Administrator Julie Anos at 11:50 AM and explained the reason for the inspection.

During today's inspection, the LPA conducted interviews with Resident #1 (R1) and Resident #2 (R2) between 12:06 PM and 12:20 PM. The LPA also conducted interviews with the Administrator at 11:50 AM, and Staff #1 (S1) and Staff #2 (S2) between 12:31 PM and 12:40 PM. At 12:42 PM the LPA reviewed records for R1 and R2.

The allegation alleges on 10/10/2021, R1 was attacked by R2 while watching TV in their room. Interviews with R1 revealed R2 tried hitting R1 but R1 was able to block R2's punches and did not sustain any injury. R1 stated they did not report this to anyone at the facility when the attack happened. During the interview with R2, R2 denied attacking R1. Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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 29-AS-20211026150433
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 MANOR, LLC
FACILITY NUMBER: 565801625
VISIT DATE: 11/03/2021
NARRATIVE
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 Interviews with staff revealed no history of R2 being aggressive toward R1 or any other residents in the facility. Record review revealed no history of R1 or R2 being aggressive while at the facility. Based on the information obtained, there is insufficient evidence to support the allegation of 'Resident attacked another Resident while in care'. Therefore, the allegation is unsubstantiated at this time.

Exit interview and report reviewed with Administrator Julie Anos. A copy of the report and appeal rights will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
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