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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206561
Report Date: 11/23/2021
Date Signed: 11/23/2021 11:59:13 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210908105203
FACILITY NAME:SUNNY GARDENFACILITY NUMBER:
107206561
ADMINISTRATOR:SANTOS, CARLOFACILITY TYPE:
740
ADDRESS:3033 E. LOS ALTOS AVETELEPHONE:
(559) 439-5760
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 5DATE:
11/23/2021
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator Carlos Santos (via telephone) and Caregiver Norrine Porciuncula TIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Facility did not seek timely medical treatment for resident.
Facility did not notify responsible parties of issues with resident's health.
Resident was unable to get assistance during night.
Staff are not wearing masks.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady Cabrera conducted the subsequent complaint investigation visit to the facility. Administrator Carlo Santos was available via telephone and designated Caregiver Norrine Porciuncula to sign the reports.

During the course of this complaint investigation LPA interviewed staff on duty, obtained and reviewed facility records. It was determined based on the interviews and records review that the above allegations are SUBSTANTIATED. Per records and interview, facility did not seek timely medical treatment for resident. Per facility Staff Notes, on 08/20/2021 at 7:30a.m., Resident (R1) complained of right hip and lower back pain prior to verbalizing that R1 “slid down” to facility staff. Facility staff did not notified RP and did not contact 9-1-1 to have R1 medically assess. Based on temperature logs and interviews, on 08/20/2021 at 8a.m. Resident’s (R1) temperature was 102.4. R1’s Responsible Party (RP) was not notified of R1’s change of condition.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 7
Control Number 24-AS-20210908105203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SUNNY GARDEN
FACILITY NUMBER: 107206561
VISIT DATE: 11/23/2021
NARRATIVE
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Per Physician’s Report dated 05/25/2021, R1 was diagnosed with Alzheimer’s Dementia and indicated R1 doesn’t know day/night and had confusion. Per R1's Appraisal dated 07/08/2021, it indicates R1 needs special observation/night supervision. Facility provided a call button to R1. Staff reported they would respond to the call button, but at times R1 did not need help. Per interviews, facility staff removed R1’s call button battery at night due to R1 would push the call button often at night and disturbed other residents.

Per interviews and LPA’s observation, on 09/14/2021, Licensee failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that facility Staff (S1) and S2 failed to wear face coverings while providing care and supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Citations are being cited on the attached LIC 9099D. Designated Caregiver was provided with the LIC9099, LIC9099D and Appeal rights provided. Exit interview conducted.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 24-AS-20210908105203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUNNY GARDEN
FACILITY NUMBER: 107206561
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2021
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance…

This requirement was not met as evidenced by:
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Licensee to review 87465 Incidental Medical and Dental Care. Licensee shall submit a written letter indicating they have read and understand the regulations to CCLD. Document of this will be provided to CCL by 12/03/2021.
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Based on records review and interviews, Licensee did not ensure to have facility staff contact 9-1-1 to have R1 medically assess, which poses a potential risk to the health, safety or personal rights of the clients in care.
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Type B
12/03/2021
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall…(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days… (D)Any incident which threatens the welfare, safety or health…
This requirement was not met as evidenced by:
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Licensee to review 87211 Reporting Requirements. Licensee shall submit a written letter indicating they have read and understand the regulations to CCLD. Document of this will be provided to CCL by 12/03/2021.
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Based on records review and interviews, the Licensee did not communicate with the R1's Responsible party regarding R1’s health condition, which poses a potential Health, Safety and Personal Rights risks to persons 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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 24-AS-20210908105203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUNNY GARDEN
FACILITY NUMBER: 107206561
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2021
Section Cited
HSC
1569.312(a)
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§1569.312 Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2.

This requirement was not met as evidenced by:
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Licensee to review 87705 Care of Persons with Dementia. Licensee shall submit a written letter indicating they have read and understand the regulations to CCLD. Document of this will be provided to CCL by 12/03/2021.
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Based on records review and interviews, Licensee did not ensure care and supervision for R1 who was diagnosed with Alzheimer’s Dementia. Per records, it indicates R1 needs special observation/night supervision. Facility staff removed R1’s call button battery at night, which poses a potential risk to the health, safety or personal rights of the clients in care.
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Type B
12/03/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations
This requirement was not met as evidenced by:
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Licensee to review 87468.1 Personal Rights of Residents in All Facilities. Licensee shall submit a written letter indicating they have read and understand the regulations to CCLD. Licensee will provide training for all staff regarding Personal Rights of Residents. The written letter and training roster will be provided to CCL by 12/03/2021.
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Based on interviews, Licensee did not ensure facility staff to wear face coverings while providing care and supervision to clients in care, which is a potential risk to the health, safety or personal rights of the 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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210908105203

FACILITY NAME:SUNNY GARDENFACILITY NUMBER:
107206561
ADMINISTRATOR:SANTOS, CARLOFACILITY TYPE:
740
ADDRESS:3033 E. LOS ALTOS AVETELEPHONE:
(559) 439-5760
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: DATE:
11/23/2021
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator Carlos Santos (via telephone) and Caregiver Norrine Porciuncula TIME COMPLETED:
11:05 AM
ALLEGATION(S):
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2
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9
Staff did not administer medications as ordered by physician.
Staff are unaware of COVID-19 mitigation protocol.
Facility does not offer residents activities.
INVESTIGATION FINDINGS:
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2
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Licensing Program Analyst (LPA) Lady Cabrera conducted the subsequent complaint investigation visit to the facility. Administrator Carlo Santos was available via telephone and designated Caregiver Norrine Porciuncula to sign the reports.

The Department has investigated the complaint alleging: Staff did not administer medications as ordered by physician, Staff are unaware of COVID-19 mitigation protocol and Facility does not offer residents activities.
LPA interviewed staff at the facility. Staff denied allegation (Staff did not administer medications as ordered by physician). LPA reviewed R1’s Medication Assistance Records and it appears medication was given as prescribed by facility staff. Per Staff Covid-19 Training records, Staff have reviewed Mitigation Plan.
Per interviews, facility does not offer residents activities. LPA interviewed Administrator and staff and reported residents are provided with activities. Per interviews, R1 would refuse to participate in activities.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 7
Control Number 24-AS-20210908105203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SUNNY GARDEN
FACILITY NUMBER: 107206561
VISIT DATE: 11/23/2021
NARRATIVE
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Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.


Designated Caregiver was provided with the LIC9099. Exit interview conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210908105203

FACILITY NAME:SUNNY GARDENFACILITY NUMBER:
107206561
ADMINISTRATOR:SANTOS, CARLOFACILITY TYPE:
740
ADDRESS:3033 E. LOS ALTOS AVETELEPHONE:
(559) 439-5760
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: DATE:
11/23/2021
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator Carlos Santos (via telephone) and Caregiver Norrine Porciuncula TIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Resident had multiple falls while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady Cabrera conducted the subsequent complaint investigation visit to the facility. Administrator Carlo Santos was available via telephone and designated Caregiver Norrine Porciuncula to sign the reports.

During the course of this investigation LPA interview staff and reviewed facility records relevant to the complaint investigation. There is no preponderance of evidence to prove the violations (Resident had multiple falls while in care) occurred as alleged by the complainant. Per interviews and records review, the Resident (R1) had a history of falls and at times refused to use her walker.This agency has investigated the complaint alleging the above violations. We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Administrator was provided with the LIC9099. Exit interview conducted.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7