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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801931
Report Date: 11/01/2022
Date Signed: 11/01/2022 10:57:09 AM

Substantiated


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
07/22/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220722130110
FACILITY NAME:SUNSHINE HEALTH PLACE 2FACILITY NUMBER:
565801931
ADMINISTRATOR:SAM MARONFACILITY TYPE:
740
ADDRESS:1482 NORMAN AVENUETELEPHONE:
(805) 304-5960
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cilva ToumeTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Staff are not meeting the resident's incontinence needs
Staff are not changing residents bandage timely
Staff are not following physicians orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent visit to deliver findings. The Administrator Cilva Toume arrived at 10:25 a.m. and the LPA explained the reason for the visit.

During the initial visit on 7/29/2022, the LPA interviewed staff at 9:15 a.m., and 9:27 a.m., interviewed residents at 9:35 a.m., 10:15 a.m., 10:20 a.m., and 10:25 a.m.; and interviewed a home health nurse at 11:50 a.m. The LPA collected pertinent documents and conducted a tour. On 8/2/2022, the LPA interviewed staff at 9:33 a.m., 9:40 a.m., and 10:15 a.m., interviewed a resident at 9:25 a.m., and observed staff administer care to Resident #1 at 9:30 a.m. Home health records were requested and reviewed.


CONT 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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 4
Control Number 29-AS-20220722130110
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: 11/01/2022
NARRATIVE
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Regarding the allegation: Staff are not meeting the resident's incontinence needs
It was alleged that staff were double diapering Resident #1 (R1). Staff interviews confirmed that staff would place two pull-ups on R1 because of R1’s bowel and bladder incontinence. During the initial visit on 7/29/2022, the LPA was informed that R1 had on two pull-ups; at the time of observation, staff reiterated that they did so due to R1’s incontinence. At the time of observation, a home health representative was providing care to R1, and the home health representative informed staff that R1 only needed one pull-up, required frequent changing, and educated staff on the concern of skin breakdown if R1 sits in a moist pull-up for an extended period of time. An interview with a home health representative communicated that R1 was at higher risk for skin breakdown with the usage of two pull-ups and required frequent changing. Besides the observed dates of 7/29/2022, a review of home health notes indicated that R1 was observed wearing two pull ups on the following dates: 5/31/2022, 6/7/2022, 7/5/2022, and 7/21/2022. Based on the information obtained from interviews, observations, and records review, there is sufficient evidence to support the claim that staff are not meeting the resident's incontinence needs. This allegation is deemed Substantiated at this time.


Regarding the allegation: Staff are not changing residents bandage timely
It was alleged that staff were not changing R1’s bandage on their left leg in a timely fashion. Records and interview indicated that R1 developed a blood blister on the left leg on approximately 7/7/2022. A review of home health records documented an order for the dressing on the wound to be changed every 2-3 days, or as needed, if the wound dressing becomes soiled. Records indicated that during a home health visit on 7/12/2022, R1’s bandage on the left leg was changed. Home health had educated the staff on the care for the left leg wound and communicated that the bandage would need to be changed every 2-3 days or if the bandage became soiled. Home health returned to the facility on 7/21/2022 and observed that the dressing in place on the left leg wound was dated 7/12/2022. Staff informed the home health representative that they had not changed the dressing as they assumed that the home health nurse was going to do so. As a result, the wound dressing had not been changed for nine (9) days. At the time of observation on 7/21/2022, the wound dressing was soiled. Thereafter, nursing visits from home health were increased to ensure the bandage was changed regularly. Staff interviews confirmed that at that time, home health nurses were changing the bandage on R1’s left leg wound every other day. Based on information obtained from interviews and record review, there is sufficient evidence to support the claim that staff did not change R1’s bandage timely. This allegation is deemed Substantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220722130110
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: 11/01/2022
NARRATIVE
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Regarding the allegation: Staff are not following physician’s orders
It was alleged that staff were not following the physician’s orders from home health related to wound care. Records review indicated that R1 developed a stage 2 pressure injury on the buttocks on approximately 5/12/2022. Interview with home health staff revealed that it was suspected that the wound developed due to poor incontinence care, not repositioning R1 timely, and utilizing two pull-ups on R1. At that time, staff were instructed to keep R1 dry, to change R1 frequently, and to apply barrier cream. Staff interviews confirmed that they provide barrier cream to R1’s buttocks timely, ensure that R1 is repositioned, and ensure that R1 is dry. A review of home health notes indicated that R1 was observed wearing two-pull ups on 5/31/2022, 6/7/2022, 7/5/2022, and 7/21/2022. During the visit conducted on 7/29/2022, LPA observed that R1 had on two pull-ups. Staff claimed that they used two pull-ups due to R1’s incontinence, yet according to home health, wearing two pull-ups can also aid in skin breakdown. A review of home health notes regarding R1’s wound on the buttocks indicated that on the following dates, the barrier cream was observed to be applied either incorrectly or minimally: 5/31/2022, 7/25/2022, 7/27/2022, and 7/29/2022. Lastly, whereas there was an order to change R1s’ bandage on the left leg wound every 2-3 days or as needed if soiled, staff did not change R1’s between 7/12/2022 – 7/21/2022, as staff assumed that the home health nurse would change the wound dressing.

Based on the information obtained from interviews and record review, there is sufficient evidence to support the claim that staff are not following physician’s orders. 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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220722130110
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: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2022
Section Cited
CCR
87625(b)(1)
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87625(b)(1) Managed Incontinence. …The licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit a Plan of Action, indicating how staff will care for residents with bladder and bowel incontinence. Submit plan of action no later than 11/3/2022.
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Based on interview and record review, the licensee did not comply with the section cited above, as R1 was double diapered due to their bladder and bowel incontinence, which poses an immediate health and safety risk to residents in care.
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2. Hold an in-service training with all staff regarding regulation 87625 Managed Incontinence. Submit sign-in sheet of completed training within the next seven days, but no later than 11/8/2022.
Type A
11/03/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. …Residents … shall have ...the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency...
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The Administrator agreed to do the following:
1. Submit a Plan of Action, indicating how staff will care for residents with bladder and bowel incontinence, as well as those with wounds. Submit plan of action no later than 11/3/2022.
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 This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff failed to follow physician’s orders related to wound care for R1, which poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4