306006518-12-12-2024-22-AS-MSTC-DCBVK4-20241226152944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006518
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:24:06 AM

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
09/13/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240913151522

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:	12/12/2024
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Eileen Tecson, licensee		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff removed resident's oxygen resulting in death
Staff yelled at a resident
Staff did not ensure that residents' incontinence needs were met

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 caregiving staff after introducing himself and stating the purpose of the visit. Administrator Eileen Tecson was notified by telephone and presented with the findings remotely.

The initial complaint investigation visit was conducted alongside a health and safety check on September 16, 2024. A tour of the physical plant and review of resident records was conducted along with an interview of the facility’s administrator via telephone. The complaint investigation was conducted by the Department as follows: Records were requested, obtained and reviewed, including: records for resident R1, R2, R3, R4 and R5 maintained at the facility (admission agreements, physician reports, physician orders for life-sustaining treatment when available, Identification and Emergency Information, pre-placement appraisal information, Appraisal/Needs and Services Plan, hospice plans of care when applicable). CONTINUED ON FORM LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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-20240913151522

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: 12/12/2024

NARRATIVE

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Resident R1 was admitted to the facility on August 7, 2024. The physician report established upon admission and dated August 22nd, 2024 states a primary diagnosis of cerebrovascular disease and orders the use of a hospital bed, wheelchair, oxygen, nebulizer and suction machine. Per R1’s pre-placement appraisal information, R1 sustained a stroke in 2007 and was paralyzed on the left side, with “hemiplegia and hemiparesis following cerebral infarction”. Resident moved into the facility from a different licensed facility as a result of a need for a higher level of care. Hospice records obtained during the investigation show an admission with Acacia Hospice and Palliative Services dated August 14, 2024. Hospice admission assessment shows that the resident was “AAOX3, able to make needs known”. Following the admission onto hospice, R1 was seen at the facility by hospice staff on August 15, 16, 18, 21, 22, 23, 29, 30 and 31. Visit notes present in the hospice records reviewed during the investigation indicate that on August 23 2024, “Dorothea was calm and took her medication normally. Fell asleep shortly after taking medication”. On August 29, 2024, she received a bed bath and appear fine. Only concern from the nurse was that she appeared “thinner”. On August 30, 2024, a hospice visit was requested due to decreased responsiveness. “[R1] woke up to take her medicine and eat lunch however was “semi responsive to verbal stimuli. Oxygen on at 3L VIA NC SPO2 90% lungs sound CTA. HR Tachycardia fever noted of 100.4 degrees and no bowel movement for the past 2-3 days. Nurse provided a Ducolax suppository. Nurse gave orders to administer a Tylenol suppository if fever persisted and to take aspiration precautions”. R1 is then stated to have passed away peacefully on August 31, 2024. R1’s death certificate was obtained during the investigation and lists the immediate cause of death as “cardiac arrest lasting a matter of minutes“ and “unspecified cerebrovascular disease”.

Regarding the allegation that Staff removed resident's oxygen resulting in death, the following has been concluded: Based on a review of resident records, hospice and hospital records, incident reports and interview conducted, R1’s indicated cause of death is “cardiac arrest lasting a matter of minutes“ and “unspecified cerebrovascular disease” with no mention of the potential consequences of being deprived of medical oxygen. Furthermore, the information obtained during the investigation does not match the elements of the allegation which indicated that R1 passed away on August 30, 2024 following the alleged removal of oxygen by staff on the same date. Hospice records additionally confirm the provision of oxygen on August 30, 2024. Hospice staff is documented to have been present at the time of R1’s passing at approximately 8am on August 31, 2024. Hospice records additionally confirm oxygen administration was overseen by hospice staff. Patient orders generated upon hospice admission on August 14, 2024 confirm the Oxygen to have been provided as needed for shortness of breath. CONTINUED ON FOR LIC9099-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240913151522

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: 12/12/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099-C
The evidence gathered therefore does not support the allegation.

Regarding the allegation that Staff yelled at a resident, the following has been concluded: Based on observation conducted during multiple facility visits along with three separate witness interviews, no occurrence of yelling or inappropriate verbal conduct on behalf of staff could be evidenced. Multiple witnesses interviewed indicated that residents diagnosed with dementia occasionally screamed or expressed themselves loudly during their visits but denied ever witnessing or being told about members of staff reciprocating or yelling at the individuals in care.

Regarding the allegation that Staff did not ensure that residents' incontinence needs were met, the following has been concluded: Based on observation conducted during multiple facility visits along with three separate witness interviews, no smells or odors could be evidenced during visits. Additionally witnesses confirmed that during their visits, both planned and unplanned, they had never witnessed their relatives needing overdue incontinence care or had noticed any odors that could be associated with poor management of incontinence by staff.

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

An exit interview was conducted with Administrator and a copy of this report was provided to a facility representative after permission was given to caregiving staff to sign the present report.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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