565801682-1-10-2022-29-AS-JAPL-CBBSFY-20220204125104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801682
Report Date: 01/10/2022
Date Signed: 01/10/2022 12:55:20 PM

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
10/21/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20211021091951

FACILITY NAME:	SUNSHINE HEALTH PLACE		FACILITY NUMBER:	565801682
ADMINISTRATOR:	SLIM MARON		FACILITY TYPE:	740
ADDRESS:	1558 NORMAN AVENUE		TELEPHONE:	(805) 446-3100
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	01/10/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cilva Toume		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff made inappropriate sexual advances to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit to deliver the findings. The LPAs met with Administrator Cilva Toume and explained the reason for the visit.

During the initial visit conducted on 10/22/2021, LPA Salia Walker conducted a plant tour at 9:50 a.m., interviewed staff from 9:05 a.m. – 10:41 a.m., completed a file review from 11:06 a.m. – 11:48 a.m., and interviewed residents from 10:41 a.m. – 1:05 p.m. During a visit conducted on 11/19/2021, LPA Ashley Smith and LPA Elsie Campos conducted observations from 9:00 a.m. - 9:45 a.m., interviewed a Resident #1 (R1) at 9:05 a.m., interviewed staff at 9:45 a.m. and 1:10 p.m., conducted a medication audit from 10:10 a.m. - 11:00 a.m., and observed a resident's bedroom at 10:40 a.m.

CONT 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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 29-AS-20211021091951

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: SUNSHINE HEALTH PLACE	FACILITY NUMBER: 565801682
	VISIT DATE: 01/10/2022

NARRATIVE

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Regarding the allegation: Staff made inappropriate sexual advances to resident in care
It was alleged that Staff #1 (S1) made sexual advances towards R1. A file review revealed that a similar allegation was made in complaint control # 29-AS-20210603101611, in which R1 made claims that staff at this facility were sexually abusing them. That allegation was unsubstantiated. Interviews with witnesses, staff, and residents negated claims that this took place. During that investigation, the LPA interviewed S1, whom commented that R1 continually made allegations that S1 was a ‘homosexual’ and making sexual advances toward R1, yet S1 repeatedly negated these claims and stated that the claims made them uncomfortable. Interviews conducted with staff revealed that they have not observed their coworkers acting inappropriately with residents, and were trained to report all types of abuse, both observed, overheard, and/or disclosed. Regarding this complaint, it was confirmed that S1 no longer works at this facility due to the repeated claims. Resident interviews revealed that residents feel comfortable residing in this facility and believe they are being treated well. Residents denied claims of abuse from staff and stated that staff maintained appropriate relationships and boundaries with the residents.
Based on the investigation, there is insufficient evidence to support the claim that staff made inappropriate sexual advances to R1. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited regarding this allegation at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 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, 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
10/21/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20211021091951

FACILITY NAME:	SUNSHINE HEALTH PLACE		FACILITY NUMBER:	565801682
ADMINISTRATOR:	SLIM MARON		FACILITY TYPE:	740
ADDRESS:	1558 NORMAN AVENUE		TELEPHONE:	(805) 446-3100
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	01/10/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cilva Toume		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff are not administering medication(s) to resident according to physicians instructions.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20211021091951

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: SUNSHINE HEALTH PLACE	FACILITY NUMBER: 565801682
	VISIT DATE: 01/10/2022

NARRATIVE

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Regarding the allegation: Staff are not administering medication(s) to resident according to physician’s instructions.

It was alleged that R1 was not getting their medications consistently. Interviews with residents revealed that in general, they believed they received their medication on time and were unaware of any errors. During the medication audit conducted on 11/19/2021, it was revealed that the facility could not account for R1’s Atorvastatin, as it was not centrally stored with R1’s other medications. Staff interviews revealed that when the Atorvastatin was delivered, R1 got upset that it was being centrally stored and allegedly argued with Staff #2 (S2) about the medication. As such, S2 admitted that they gave R1 the medication to store in their room. As such, staff were unable to ensure that R1 was taking the Atorvastatin according to physician’s instructions. In addition, a review of the Centrally Stored Medication and Destruction Record (CSMDR) revealed that R1’s prescribed evening dosage of Quetiapine (Seroquel) was documented as Refused in the section Start Date. Interviews further confirmed that R1 had a prior history of refusing the evening dosage of Quetiapine. As such, rather than offer R1 their evening medication of Quetiapine and giving R1 the option to refuse, S1 admitted to not giving R1 their evening medication as prescribed on 11/19/2021. S1 claimed that they stored it in their room, and then threw the medication away. The LPA could not identify evidence to demonstrate that R1’s repeated refusal was communicated to R1’s primary care physician.

During a visit conducted on 11/19/2021, LPA Smith was granted access to tour R1’s room. The LPA observed several loose pills in R1’s drawer, which were identified as Quetiapine pills. In addition, the LPA observed two bottles of medications. One medication was identified as Crestor, and the other pill box had a mix of multiple unidentified medications. After touring R1’s room, the LPA alleged that the loose Quetiapine pills were from times in which staff attempted to assist R1 with the evening dosage of Quetiapine and rather than observing R1 taking the medication, the pill(s) were left with R1 and staff assumed that R1 took the medication.

Based on the investigation, there is sufficient evidence to support the claim that staff were not assisting R1 with the self-administration of medication(s) according to physician’s instructions. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report, and appeal rights, were issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20211021091951

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: SUNSHINE HEALTH PLACE	FACILITY NUMBER: 565801682
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/17/2022 Section Cited CCR 87465(a)	1 2 3 4 5 6 7	87465(a)(5) Incidental Medical and Dental Care. (5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to the following: 1. Submit a Statement of Understanding, noting how the facility will maintain compliance with Regulation 87465. Submit statement to CCL by POC date.
	8 9 10 11 12 13 14	Based on observation and interview, the licensee did not comply with the section cited above regarding R1’s evening dosage of Quetiapine or Atorvastatin, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	2. Complete an in-service medication training for staff. Be sure to discuss protocol for administering medications and documenting refusals. Submit proof of completion to CCL by POC due date.
Type B 01/17/2022 Section Cited CCR 87465(i)	1 2 3 4 5 6 7	87465(i) Incidental Medical and Dental Care. Prescription medications which are not taken with the resident ... which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: Complete an in-service medication training for staff. Be sure to discuss protocol for administering medications and documenting refusals. Submit proof of completion to CCL by POC due date.
	8 9 10 11 12 13 14	Based on observation and interview, the licensee did not comply with the section cited above, as staff admitted to improperly disposing of R1’s medications in the trash can, which poses a potential health and safety risk to 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5