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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004407
Report Date: 10/14/2022
Date Signed: 10/14/2022 05:08:10 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Shobhana Frank
COMPLAINT CONTROL NUMBER: 22-AS-20210907151351
FACILITY NAME:ROSSMOOR SUNSHINE VILLA-FOSTERFACILITY NUMBER:
306004407
ADMINISTRATOR:RICARDO BANOSFACILITY TYPE:
740
ADDRESS:12521 FOSTER ROADTELEPHONE:
(562) 572-9931
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 6DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Staff April CalaycayTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility failed to provide adequate supervision resulting in fall
Facility failed to provide preventative measures for scabies
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Shobhana Frank for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met
with Staff April Calaycay and explained the reason for today’s visit.

During the course of investigation LPA Shobhana Frank reviewed Special Incident Report (SIR), R1 Physician’s report, conducted interviews at facility with Staff 1 (S1) Staff 2 (S2) Staff 3 (S3)
Investigation on allegation Facility failed to provide adequate supervision resulting in fall is as below.

Interviews were conducted with S1, S2, and S3 whom did not corroborate allegation. As S3 denied allegation and stated that it happened so fast, she was in R 1’s room checked on her and went to next door R 2”s room to checked and in few second she heard a something fall in R1’s room and came back right away. She observed R1 was seated on the floor and stated she accidently slipped from her bed.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
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 22-AS-20210907151351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSSMOOR SUNSHINE VILLA-FOSTER
FACILITY NUMBER: 306004407
VISIT DATE: 10/14/2022
NARRATIVE
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Investigation on allegation Facility failed to provide preventative measures for scabies is as bellow.
Interviews were conducted with S 1, S 2 and S3 whom denied allegation and stated that Facility was following all orders from her primary care doctor. R 1 was treated with her prescribed medication and isolated protocol was being followed with universal precaution for all residents and staffs. Home health nurse was following up and continue to monitor her condition. While R1 was diagnosed with scabies, scabies outbreak was not suspected at the facility.
Therefore, the allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there are no preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegations of Facility failed to provide adequate supervision resulting in fall and Facility failed to provide preventative measures for scabies are deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator and a copy of report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2