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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801625
Report Date: 02/19/2025
Date Signed: 02/19/2025 01:23:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
02/13/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20250213093029
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: 48DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Cathalina Anos-Hipolito TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Inadequate staff supervision resulting in resident ingesting another resident's medication(s) while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:45 a.m., the LPA met with Administrator Assistant, Cathalina Anos-Hipolito and explained the reason for the visit.

Starting at 9:58 a.m., the LPA conducted interviews with three (3) staff, five (5) clients and the Administrator, Juliana Anos. At 10:05 a.m., the LPA obtained copies of pertinent documents. At 10:20 a.m., the LPA along with the Administrator Assistant conducted a physical plant tour.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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-20250213093029
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE MANOR, LLC
FACILITY NUMBER: 565801625
VISIT DATE: 02/19/2025
NARRATIVE
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Regarding the allegation: Inadequate staff supervision resulting in resident ingesting another resident's medication(s) while in care. It was alleged that due to inadequate staff supervision Client #1 (C1) took and ingested another client’s medications. Staff and Administrator interviews confirmed that on 02/06/2025, C1 went to get C1’s morning medication and instead picked up and ingested another client’s medication. Staff #1 (S1) explained that medications are passed out in the dinning room. S1 stated that medications are prepared by the Administrator prior to passing them out and are placed inside little cups that are labeled with each client’s name. Then the cups are placed on a tray and each client goes up to staff to grab their cups and ingest their medications in front of the staff. S1 stated that normally staff ensure that clients are taking and ingesting their own cups and medications, however when C1 took the incorrect cup staff did not notice as staff were eating breakfast during that time. S1 stated that C1 noticed that C1 ingested the wrong medications and notified staff immediately. Shortly after, the ambulance was called for C1 and C1 was transported to the hospital for observation. The Administrator sent the Department an unusual incident/ injury report on 02/10/2025 regarding the incident. S1 stated that medication training was scheduled for 02/19/2025 for all staff. S1 stated that medication training is being conducted by an outside vendor. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250213093029
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SUNRISE MANOR, LLC
FACILITY NUMBER: 565801625
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2025
Section Cited
CCR
80075(b)
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80075(b) Health Related Services(b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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The Administrator stated the following will be done: 1. Medication training has been scheduled for 02/19/2025. Verification of scheduled training and completion with the trainers credentials will need to be submitted by 02/21/2025.
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Based on interviews, the licensee did not comply with the section cited above, as a medication error occurred on 02/06/25 regarding C1, which poses an immediate health and safety risk to clients 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3