565801931-5-5-2021-29-AS-JAPL-C2RT25-20210506142008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801931
Report Date: 05/05/2021
Date Signed: 05/05/2021 09:48:36 AM

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
09/01/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20200901153501

FACILITY NAME:	SUNSHINE HEALTH PLACE 2		FACILITY NUMBER:	565801931
ADMINISTRATOR:	SAM MARON		FACILITY TYPE:	740
ADDRESS:	1482 NORMAN AVENUE		TELEPHONE:	(805) 304-5960
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cilva Toume		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Lack of supervision resulting in resident sustaining fracture
Staff failed to notify residents family and physician of change in condition

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena conducted a subsequent complaint investigation to deliver the findings for the above allegation. The LPA met with Administrator Cilva Toume and explained the reason for the visit.

On 9/1/2020, the Department received a complaint stating that on 8/26/2020, Resident #1 (R1) fell out of bed and broke their left hip. In addition, it was alleged that R1 and other residents were being overmedicated. Community Care Licensing Division’s Investigations Branch (IB) Investigator Jose Santana was assigned to the case. During the 9/2/2020 visit, LPA Desaree Perera conducted a virtual tour at 1:15 p.m., interviewed the Administrator at 1:25 p.m. and requested documents. LPA Smith conducted a medication audit on 4/27/2021 at 9:36 a.m. Investigator Santana interviewed a family member 9/9/2020, attempted to interview R1 on 9/10/2020, reviewed medical and investigative records on 9/10/2020, 9/11/2020, 9/14/2020, 9/21/2020, and 9/26/2020; interviewed a collateral agency staff on 9/11/2020; interviewed two staff members on 9/30/2020; interviewed hospice staff on 10/15/2020; and, conducted three additional staff interviews on 10/20/2020.

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: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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-20200901153501

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 2	FACILITY NUMBER: 565801931
	VISIT DATE: 05/05/2021

NARRATIVE

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Regarding the allegation: Lack of supervision resulting in resident sustaining fracture

It was alleged that R1 sustained a fractured left hip due to inadequate care and facility neglect. Records reviewed and interviews conducted confirmed that prior to R1’s admittance facility on 8/20/2020, R1 fell on approximately 8/1/2020. As a result, medical records revealed that R1 suffered a fractured right wrist and right hip pain. R1 continued to express pain in their right thigh, so a hospital visit on 8/10/2020 confirmed that R1 did not suffer any fractures of the right femur or hip. Yet, as R1 only complained of pain in the right thigh, there were no imaging records for R1’s left hip to assess whether there was a fracture or any injury. R1 was diagnosed with osteoarthritis and R1 was unable to bear weight on their right leg. R1 was admitted to this facility on 8/20/2020 and was concurrently admitted to hospice.

A review of the hospice Plan of Care and facility appraisals confirmed that R1 was deemed a high risk for falls. In response, the facility implemented a fall mitigation plan. Hospice ordered a full bedrail, a floor mattress next to R1’s bed, and instructions for R1 to use a wheelchair or two-front wheel walker for ambulation. Staff were also instructed to lower R1’s bed to the lowest setting, which staff complied. Staff interviews revealed that on at least three occasions, R1 attempted to ambulate without the use of a walker or wheelchair, yet these instances did not result in a fall or injury. A review of medical records dated 8/18/2020 revealed that R1 tended to get up and wander, despite pain to their right hip. Similar observations were documented by hospice nurses whom would provide care for R1. Due to R1’s cognitive decline, hospice noted that R1 would attempt to get up as R1 truly believed they could ambulate without assistance.

On the evening of 8/25/2020, Staff #1 (S1) and Staff #2 (S2) were on duty. S1 and S2 checked on R1 at least once during NOC shift and noted that R1 was asleep. At 4 a.m., S1 was awoken by R1’s call for help, and S1 entered the bedroom and saw R1 on the floor. At the time of the unwitnessed fall, the full-bedrail was on the bed; however, there was a gap between the end of the bedrail and the footboard which is about 10 inches wide, which is how staff assumed that R1 slid out of bed. S1 asked R1 if they were hurt, and R1 did state that their hip hurt. However, R1 did not specify if it was the left or right hip, so S1 assumed it was the right hip, which was an existing pain. R1 was put back to bed, and S1 did not call 9-1-1 or inform the Administrator as S1 did not think it was an emergency. The Administrator arrived at the facility at 8 a.m. and was notified of R1's fall. In the morning, R1 expressed pain, thus the Administrator called hospice and requested an x-ray. An X-ray of the left hip was taken at 11:40 a.m. on 8/26/2020 and it was then discovered that R1’s left hip was fractured. The Administrator called 9-1-1 at 4:55 p.m. R1 was admitted to the hospital at 5:26 p.m. and the x-ray showed that R1 sustained an acute, comminuted intertrochanteric left hip fracture.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200901153501

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 2	FACILITY NUMBER: 565801931
	VISIT DATE: 05/05/2021

NARRATIVE

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Per the investigation, the facility implemented fall prevention measures as instructed by hospice. In addition, hospice had instructed the facility to provide R1 with Ambien to at bedtime to assist R1 with sleeping, which was indeed administered per the medication administration records. Whereas staff do not conduct status checks throughout the night, all fall prevention measures were in place, and S1 immediately responded once alerted to R1’s fall. However, even if status checks were performed every two hours while R1 was in bed, the investigation concluded that R1 could have attempted to get out of bed in between such checks. Based on the investigation, there is insufficient evidence to support the claim that lack of supervision resulting in resident falling and sustaining fracture. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff failed to notify residents family and physician of change in condition
It was alleged that R1’s family and physician were unaware of the medication changes. A review of hospice documents and R1’s medication record indicated that R1 was prescribed Zolpidem (Brand name: Ambien) and alprazolam (Brand name: Xanax) by R1’s hospice attending physician on 8/20/2020. The zolpidem was prescribed to be given once every night due to R1’s insomnia and the alprazolam was prescribed to be given up to three times a day as needed for anxiety. It appeared that the two medications were a standing order from the time that R1 was admitted to the facility on hospice. Interviews and records review stated that a hospice representative was present during R1’s admittance to the facility on 8/20/2020, and that hospice recalled explaining the medication regime to the facility staff and R1’s family. Hospice notes reflected that there was discussion around ensuring that R1 does not take Ambien and Xanax together, to which the family and facility staff verbalized understanding.

Based on interview and record review, a change of medication did not transpire during the time that R1 was in the facility from 8/20/2020 – 8/26/2020. The only change of condition throughout R1’s time at the facility was in terms of the fall from 8/26/2020, and the family and R1’s physician was notified of the fall. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Signatures obtained. A copy of the report was provided to the Administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
09/01/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20200901153501

FACILITY NAME:	SUNSHINE HEALTH PLACE 2		FACILITY NUMBER:	565801931
ADMINISTRATOR:	SAM MARON		FACILITY TYPE:	740
ADDRESS:	1482 NORMAN AVENUE		TELEPHONE:	(805) 304-5960
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cilva Toume		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Staff are overdosing residents

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: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20200901153501

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 2	FACILITY NUMBER: 565801931
	VISIT DATE: 05/05/2021

NARRATIVE

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Regarding the allegation: Staff are overdosing residents
It was alleged that R1 and the other facility residents were being overmedicated. A review of R1’s list of medications and R1’s medication administration record (MAR) indicated that medications were administered as prescribed. The LPA conducted a medication audit on 4/27/2021 at 9:36 a.m., and the LPA reviewed medications for the current six residents. Out of the six residents, the LPA observed that one out of six residents (R2) were receiving an extra dosage of medication. The prescription for the pain medication stated Take 1 capsule by mouth every 4 hours as needed for pain. Max 4 per day. A few of the medication administration record (MAR) for R2 revealed that R2 was receiving upwards to five pills per day. The Administrator confirmed that R2 requested additional medication and they were unaware that the max amount that should be given for the medication is four pills per day.

Based on the investigation, whereas there is insufficient evidence to support the claim that R1 was overmedicated, there is a preponderance of evidence that one out of the six residents (R2) currently admitted to the facility is overmedicated. 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, today's report and appeal rights were reviewed and issued. Signatures were obtained.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20200901153501

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 2	FACILITY NUMBER: 565801931
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/07/2021 Section Cited CCR 87465(a)(6)(A)	1 2 3 4 5 6 7	Assistance with self-administered medications shall be limited to the following: Medications usually prescribed for self-administration which have been authorized by the person's physician. 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 reviewing prescription labels. Submit proof of completion to CCLD by 5/7/2021.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the section cited above, as staff administered additional medications to one out of six residents (R2) which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

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