<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609684
Report Date: 06/25/2022
Date Signed: 06/25/2022 12:31:54 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210524134532
FACILITY NAME:SUNNYBRAE HOMEFACILITY NUMBER:
197609684
ADMINISTRATOR:SAVELLA, JEFFREYFACILITY TYPE:
740
ADDRESS:8001 SUNNYBRAE AVETELEPHONE:
(323) 455-7821
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 6DATE:
06/25/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Josephine EspirituTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained multiple pressure injuries while in care

Staff did not address a resident's change in level of care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA spoke with administrator and explained the reason for this visit.

Regarding the allegation above, it is alleged that resident #1 (R1) sustained multiple pressure injuries while in care at this facility before being admitted to the hospital on 4/28/21. LPA conducted initial visit on 05/25/2021 to interview facility staff and obtain copies of pertinent documents related to R1’s care. LPA conducted a follow up visit on 08/06/2021 to interview staff and obtain more documentation. On 05/27/2022, LPA was able to obtain medical records from Kaiser regarding R1’s care before entering the facility and after R1 left the facility on 04/28/2021. Information obtained from interviews reveal that R1 was admitted from Canyon Oaks Skilled nursing to the facility on 04/20/2021 and stayed at the facility until 04/28/2021 when R1 was admitted to the hospital due to an emergency call.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
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 2
Control Number 31-AS-20210524134532
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNNYBRAE HOME
FACILITY NUMBER: 197609684
VISIT DATE: 06/25/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A review of R1’s medical records show that before R1 was admitted to the facility, R1 had an ulcer on their right foot and a left shoulder fracture. While in the facility, R1 was receiving home health services on their left shoulder and was being treated for the ulcer on their right foot. On 04/28/2021, R1 had chest pain and emergency services were called. R1 was admitted to Kaiser Hospital. LPA reviewed R1’s hospital records from when R1 was admitted on 04/28/2021 and the care R1 received at the hospital afterwards. A review of R1’s medical records show that when R1 was admitted to the hospital on 04/28/2021, R1 did not have any pressure injuries.

Based on the information obtained through interviews and a review of R1’s medical records, this allegation is deemed unsubstantiated at this time.

Staff did not address a resident's change in level of care


It is alleged that the facility did not address R1's change in level of care while at the facility. Interviews were conducted with facility staff and R1's responsible person. LPA also reviewed R1's medical records which detailed the R1's medical issues and care provided. Information obtained from interviews and medical record review does not show that the facility failed to address any change in the level of care to which R1 was receiving while at the facility. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Exit Interview conducted. Copy of report issued.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2