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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700781
Report Date: 08/30/2021
Date Signed: 08/30/2021 05:15:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2021 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20210517115650
FACILITY NAME:SUNNY PEACE 1FACILITY NUMBER:
342700781
ADMINISTRATOR:CARRASCO IV, EUFRONIOFACILITY TYPE:
740
ADDRESS:6204 FENNWOOD CT.TELEPHONE:
(619) 861-6339
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: DATE:
08/30/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria CarrascoTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility failed to issue a refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio met with Licensee Maria Carrasco, explained the purpose of the visit, and confirmed that staff and residents have not experienced any signs or symptoms of COVID-19 in the last ten days.
 
The investigation was conducted by LPA Valerio and consisted of interviews with Licensee Maria, facility staff, and Reporting Party (RP). Medical records and facility records were obtained and reviewed. The Department has determined the following as it relates to the above complaint allegation.




Continued on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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 4
Control Number 27-AS-20210517115650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SUNNY PEACE 1
FACILITY NUMBER: 342700781
VISIT DATE: 08/30/2021
NARRATIVE
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Continued from LIC 9099...
LPA Valerio conducted interviews with the administrator and facility staff on 05/20/2021 and 06/26/2021. During the interviews, the Administrator Euforino and facility staff could not remember the exact dates of Resident 1 (R1) stay at Sunny Peace 1. Administrator Eurforino stated R1 was at the facility from 12/23/21 to 12/31/21. Facility medical records showed medications were given to R1 on dates 12/24/21 until the morning of 12/31/21.

LPA Valerio reviewed the facility's Admission Agreement, section 9, discusses the Refund Policy. The refund policy states the following:
A. The Agreement must indicate whether or not all, or any portion(s), of a payment will be refunded. There are no preadmission fees or deposits against damages being charged prior to the resident moving in or during the resident's stay.
B. Refunds will be granted as follows: If the resident has to move for a higher level of care, a refund will be delivered within two weeks after all of the residents items have been removed.
(See attached policies if the Department orders a relocation order or when the resident dies)
C. If the resident leaves the facility temporarily, the holding rate for his/her room is $___ per day. The total monthly rate set forth in the admission agreement __ will _x_will not be prorated on a daily basis upon the resident's admission to, or permanent departure from, the facility during the month.
H&S Code Section 1569.884

LPA Valerio reviewed American River Home Care medical records for R1, electronically signed on 01/02/2021. According to medical records, R1 was transferred to Kaiser South on 12/28/2021. According to RP, R1 was at the facility from 12/23/21 until 12/28/21. R1 did not return to the facility due to needing a higher level of care. The RP confirmed that they did not receive or complete discharge paperwork for R1.

LPA Valerio attempted to review R1's inventory sheet to determine the length of time R1's belongings were in the facility. Administrators informed LPA Valerio an inventory sheet was not completed for R1.


Continued on LIC 9099-C Page 3...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210517115650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SUNNY PEACE 1
FACILITY NUMBER: 342700781
VISIT DATE: 08/30/2021
NARRATIVE
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Continued from Page 2 LIC 9099- C...

The RP and Administrator of Sunny Peace 1 stated they communicated via phone regarding R1's hospital stay, admission agreement, and refund. LPA Valerio learned there were no documentation of alleged conversations.

Based on LPA's interviews, medical record review, and facility record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.  California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099-D.  Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.

An exit interview was held with Licensee Maria Carrasco and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210517115650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNNY PEACE 1
FACILITY NUMBER: 342700781
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited
CCR
87507(f)
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87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by:
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Licensee stated she will review the current admission agreement, update as needed, and ensure to adhere to agreed admission agreement with residents and responsible parties. Licensee will send amended admission agreement to LPA via e-mail by POC due date.
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Based on interviews and record review, the licensee did not follow their refund policy as stated in their admission agreement. Licensee did not issue a refund after R1 was transferred to the hospital and did not return to facility. This poses a potential health and safety risk to residents 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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4