306006518-10-30-2024-22-AS-SSAS-DAK6RL-20241030210230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006518
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:35:14 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
08/01/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240801112858

FACILITY NAME:	SUNNY COAST CARE HOME		FACILITY NUMBER:	306006518
ADMINISTRATOR:	BULLER, KATHRINA		FACILITY TYPE:	740
ADDRESS:	1615 KENT LANE		TELEPHONE:	(714) 749-9353
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92660
CAPACITY:	6	CENSUS: 6	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Kathrina Buller, Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Resident developed a pressure injury while in care due to staff neglect.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by facility after introducing himself and stating the purpose of the visit. Administrator Buller was notified and informed of the findings by telephone.
The initial complaint investigation visit was conducted alongside a health and safety check on August 2, 2024. A tour of the physical plant and review of resident records was conducted along with an interview of the facility’s administrator. The complaint investigation was conducted by the Department as follows: Records were requested, obtained and reviewed, including: records for resident R1 maintained at the facility (admission agreement dated June 9, 2024, physician report dated June 9, 2024, physician orders for life-sustaining treatment, Identification and Emergency Information, pre-placement appraisal information, Appraisal/Needs and Services Plan, physician’s orders dated August 1, 2024, nephrology orders) and discharge documents from Fountain Valley Post Acute dated June 6, 2024.
CONTINUED ON FORM LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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 22-AS-20240801112858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY COAST CARE HOME	FACILITY NUMBER: 306006518
	VISIT DATE: 10/30/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099
Resident R1 was admitted to the facility on June 9, 2024, with a primary diagnosis of “Acute/Chronic respiratory failure, Chronic Obstructive Pulmonary Disease and atelectasis” and secondary diagnosis of “End stage renal disease [requiring] dialysis and congestive heart failure”, from Fountain Valley Post Acute with a prescription for ongoing dialysis twice weekly on Mondays and Fridays. R1 attended regular dialysis appointments while admitted at the facility.

On June 25, 2024, dialysis care staff notified facility staff that R1’s had elevated potassium levels and recommended an assessment at the hospital. R1 was admitted to Orange Coast Memorial Hospital on that day and returned to the facility on July 3, 2024. Orange Coast Memorial Hospital admission records indicate the reason of admission to be “Abnormal Labs on Dialysis” and the admitting diagnosis is stated to be sepsis due to a urinary tract infection.

Discharge notes from Orange Coast Memorial Hospital were reviewed and include an order for a placement under hospice. The list of concerns included shows the presence of an unstageable decubitus ulcer and heel ulcer at that time. Based on the multiple assessments reviewed, R1 did not present with pressure injuries of any stage prior to this hospitalization.

Upon returning to the facility on July 3, 2024, the facility staff notified R1’s responsible party about newly occurred pressure injuries as confirmed by a dated typed report. Text conversations from the administrator to R1’s responsible party show a shared concern about dietary incompatibilities that were not followed during the hospital admission. Hospice admission with Collective Hospice Care was finalized on July 13, 2024, with regular wound care being provided as documented in the hospice notes. The hospice admission diagnosis is listed as “Acute on Chronic diastolic Congestive Heart Failure” with comorbidities listed as: “hyperlipidemia, hyperkalemia, End Stage Renal Disease on hemodialysis, unstageable decubitus ulcer, heel, COPD, CAD, anemia, encephalopathy, dementia, altered mental state(…)”. In addition to the admission visit on July 13, the Collective Hospice Care made visits on July 18, July 20, July 22, July 23, July 25 and July 27, 2024.

On July 29, 2024, the licensee reported to the Department that R1 was discharged from hospice and sent out to the hospital directly from the dialysis center due to a suspicion of stroke. Upon discharge on August 3, 2024, the resident was admitted onto hospice again with a different provider, Valley Oaks Hospice as confirmed by a review of the plan of care and admission documents. CONTINUED ON LIC9099-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240801112858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY COAST CARE HOME	FACILITY NUMBER: 306006518
	VISIT DATE: 10/30/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099-C
The hospice diagnosis is listed as End Stage Renal Disease which is consistent with the initial hospice admission made in July 2024. R1 passed away from cardiac arrest on August 6, 2024. R1 had been unresponsive since August 4, 2024, and had been receiving comfort care from the hospice provider since. R1’s family member was notified and was present at bedside at the time of R1’s passing.

Regarding the allegation that Resident developed a pressure injury while in care due to staff neglect, the following has been concluded: Based on a review of resident records, hospice and hospital records, incident reports and interviews conducted, LPA did not find sufficient evidence that the occurrence of R1’s pressure injuries was attributable to facility staff neglect and/or lack of care and supervision. There is no evidence of the injuries being present prior to a hospital admission period from June 25 to July 3, 2024. Once assessed to be present, the injuries were addressed via home health and hospice services being contracted and in charge of providing wound care.

As a result of this investigation, the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with administrator Kathrina Buller via telephone and a copy of this report was provided to a facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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