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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801682
Report Date: 06/10/2023
Date Signed: 06/10/2023 12:56:45 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
04/27/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230427135953
FACILITY NAME:SUNSHINE HEALTH PLACEFACILITY NUMBER:
565801682
ADMINISTRATOR:SLIM MARONFACILITY TYPE:
740
ADDRESS:1558 NORMAN AVENUETELEPHONE:
(805) 446-3100
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
06/10/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cilva ToumeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident sustained injury while in care.
INVESTIGATION FINDINGS:
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Licensing program Analyst (LPA) Sandra Urena arrived unannounced to conduct a subsequent visit to deliver the findings for the allegation listed above. The LPA met with the Administrator Cilva Toume and explained the reason for the visit.

On 04/28/2023, Licensing program Analyst (LPA) Sandra Urena arrived unannounced at the facility at 11:55 a.m. to conduct the initial 10-day visit to investigate the allegation listed above. The LPA was greeted by staff. Staff contacted the Administrator via phone. The LPA met with the Administrator, Cilva Toume, and explained the reason for the visit. LPA conducted staff and resident interviews. During the investigation, the LPA interviewed the complainant, the administrator, hospital staff, facility staff, Resident #1 (R1) and reviewed medical records and other related documents.
Continues on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
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-20230427135953
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: 06/10/2023
NARRATIVE
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Page 2.
On the allegation that the ‘Resident sustained injury while in care’; it is the concern of the complainant that R1 alleged that staff broke both of their arms. To investigate the allegation, on 04/28/2023 at 12:10 p.m. the LPA interviewed R1 about fractures sustained while receiving care at the facility. R1 stated that fractures happened when they fell while they were walking towards the kitchen area; they tripped by the threshold between the hallway and the living room area. R1 stated that they fell forward, slightly to the right landing on the floor, while trying to soften the fall with their hands. R1 stated that they don’t know what made them trip, did not see anything in their way. Staff called 9-1-1, and R1 was taken to the hospital for evaluation.

The LPA interviewed hospital staff on 04/28/2023 from 11:00 a.m. to 11:58 a.m. The hospital staff stated that R1 was seen at the hospital two times, the first time on 04/24/2023, and then again on 04/26/2023 due to a fall. Per the hospital staff, R1 accused facility staff of breaking their arms. However, the hospital staff added that the hospital is familiar with R1 making accusations against staff and making 9-1-1 calls for non-emergency reasons. The hospital staff contacted R1’s POA (power of attorney) and asked if they were ok with returning R1 to the facility, given the statements made by R1. The POA stated that they had no problem with R1 returning to the facility once R1 was discharged from the hospital.

On 04/28/2023 at 12:20 p.m., the LPA interviewed staff #1(S1) about the fractures, and staff indicated that on 04/24/2023, R1 walking from the bedroom towards the dining room with a cup in their hands; suddenly S1 heard R1 scream and saw R1 on the floor. Per S1, they tried to assist R1 to get up but, R1 complained of pain. Staff called 9-1-1 first, then they contacted the administrator. S1 further stated that they attended to R1 while the paramedics arrived. S1 stated that R1 returned from the hospital to the facility on the same day (04/24/2023) in the evening. S1 stated that the R1 seemed sedated and slept through the night. R1 did not start complaining about pain until the next day. The R1 continued to complain about pain; consequently, R1’s POA was contacted to inform them that they would be sending the R1 back to the hospital due to the pain. When R1 returned from the hospital the second time, they came back with the diagnosis of ‘fractured upper arms’ (humerus). The humerus bone is the long bone located in the upper arm between the shoulder joint and the elbow joint.

Continues on LIC 9099C...
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230427135953
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: 06/10/2023
NARRATIVE
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Page 3.
On 04/28/2023 at 12:40 p.m., the LPA interviewed the administrator about the fractures sustained by R1. The administrator stated that R1 was taken to hospital the day of the fall; however, R1 was returned to the facility at around 9:30 p.m. on the same day. Hospital discharge papers did not indicate that R1 had sustained fractures. The following day, R1 started to complain of pain, and 9-1-1 was called again, and R1 was taken back to the hospital. Upon return, the hospital diagnosed R1 with humerus fractures. Furthermore, the administrator added that R1 refuses to use a better pair of slippers, given that the ones R1 uses now, are extremely worn out, making them a tripping hazard. The resident owns a better pair of slippers and still chooses to use the old ones.

The LPA conducted a medical record review, and physician’s report on 04/28/2023. The record review was pertaining to the two admissions of R1 to the hospital due to the fall at the facility. Regarding the hospital visit on 04/24/2023, the records indicated the following diagnosis: “Extremities- Moving extremities freely x 4. Musculoskeletal-R1 denies injury. Back-Gross range of motion intact. Neurologic- Alert and oriented. R1 answers questions appropriately. No gross motor weakness. Speech clear.” The report does not indicate if R1 received X-rays for further evaluation of potential fractures or was recommended to receive X-rays. Regarding the hospital visit on 04/26/2023, the records indicated the following diagnosis: “Patient fell two days ago and broke both humerus bones (upper arms). This is treated with immobilization.” Physician’s report indicates that R1 is ambulatory.

Based on the information gathered through interviews and record reviewed; the investigation revealed that although R1 sustained an injury while in care, the injury did not happen due to staff inflicting the injury. Staff have encouraged the resident to wear better slippers. The resident owns a better pair of slippers and still chooses to use the old ones. Facility staff provided R1 with immediate care, and emergency services were contacted. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3