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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920136
Report Date: 10/22/2024
Date Signed: 10/22/2024 05:15:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240702083338
FACILITY NAME:SUNRISE VILLAGE LLC, THEFACILITY NUMBER:
345920136
ADMINISTRATOR:LEYLA ARDELEANFACILITY TYPE:
740
ADDRESS:7948 SUNRISE BLVDTELEPHONE:
(916) 412-6190
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 2DATE:
10/22/2024
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Carmen Bujor,Administrator DesigneeTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff does not ensure reporting requirements are followed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 7/2/24. LPA met with Rodica Herlea, caregiver, who contacted Valentina Ciornea, Administrator, who was initially not available. Carmen Bujor, Administrator Designee arrived shortly to the facility. LPA was advised there are currently (2) residents and (1) resident, who was under hosipce care, passed this morning. Administrator arrived around 3:45 pm.

**The entire management of the facility and the corporation ownership changed on 10/1/24. None of the staff and management referenced in this report are currently associated to the facility. There was no communication with the Licensee regarding this resident.**

During the investigation, LPA interviewed the Administrator, House Manager, (2) care staff, home health personnel, resident (R1) and (1) family member. Documentation was reviewed, including but not limited to: home health records and physician's report. The results of the investigation are as follows:

**cont on 9099C-1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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 5
Control Number 59-AS-20240702083338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNRISE VILLAGE LLC, THE
FACILITY NUMBER: 345920136
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2024
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements -(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:

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Licensee/Administrator agree to read Reg 87211 and submit a signed statement that it is understood and to alsoconduct training on fall prevention, methods of properly caring for residents with Dementia and Agitation, one or two person transfer, initial skin assessment
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Based on interviews conducted and edocumentation reviewed, the Licensee did not ensure an incident report was submitted timely, within (7) days, to the Department and to the responsible person of resident (R1), following an injury on/around 6/10/24 and 6/17/24, which posed 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: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240702083338

FACILITY NAME:SUNRISE VILLAGE LLC, THEFACILITY NUMBER:
345920136
ADMINISTRATOR:LEYLA ARDELEANFACILITY TYPE:
740
ADDRESS:7948 SUNRISE BLVDTELEPHONE:
(916) 412-6190
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 2DATE:
10/22/2024
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Carmen Bujor,Administrator DesigneeTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
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The results of the investigation are as follows:

During the investigation, LPA interviewed the Administrator, House Manager, (2) care staff, home health personnel, resident (R1) and (1) family member. Documentation was reviewed, including but not limited to: home health records and physician's report. Licensee and LPA phoned the House Manager during today's inspection.

Resident (R1) moved to the care home on 6/3/24 after being discharged from a skilled nursing facility with a diagnosis of Hypertension and Peripheral Vascular Disease/Dementia. Resident was able to communicate needs and follow directions, and was incontinent with bladder/bowel. Resident required a 1-person assist with bathing, dressing, toileting, medication and occasionally with eating. Resident was experiencing hallucinations and agitation when moving in. (R1) was admitted to home health on 6/6/24 for the primary purpose of fall prevention and medication management.


The results of the investigation are as follows:

*cont on 9099AC-1..

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240702083338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNRISE VILLAGE LLC, THE
FACILITY NUMBER: 345920136
VISIT DATE: 10/22/2024
NARRATIVE
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9099AC-1.. Allegation: Resident sustained unexplained injuries while in care. The allegation states resident (R1) was observed to have multiple bruises on arms and legs at different stages of healing.

The House manager stated resident used a wheelchair only, was out of bed part-time and that (R1) moved in with bruises, but she did not document or take any photos of the bruises. Both the House Manager and staff (S1) stated that by the second week, (R1) was able to leave their room and be in the common areas.

(S1) stated to LPA on 7/9/24, that (R1) didn't like to be changed, did not fall and never went to the hospital during her three- week stay at the board and care. Resident's family member, the Administrator at the time, and the House Manager also indicated (R1) was never sent to the hospital.

A home health staff stated "(R1) did not move in with any bruises", as they saw (R1) at the "initial visit, which was one week after move in" and (R1) only had a small abrasion on her cheek at that time. The home health staff stated they observed bruises on (R1) "two weeks after (R1) moved in", and was told by care staff at that time that (R1) will get up at night and fell.

Home Health notes confirm that on 6/10/24, home health staff observed a "skin abrasion on the right cheek" and that facility staff stated (R1) hit her cheek on her bed when trying to get out of bed during the night. The home health nurse assessed the wound and requested wound care orders.

Resident's family member stated that the House Manager would state her staff “were gentle”, but she was told by two home health staff that the bruises were “not consistent with the types of falls the facility said she had” and the bruising was “oval in shape, like a person’s hand-prints. The family member stated the House Manager had told her that (R1) “moved in with the bruises”.

Resident's family member stated that (R1) told her there were (2) female caregivers that lived at the care home, and she thinks the one who worked at night is “meaner” based on what (R1) said and that staff "would grab her tight”.

Home health notes from 6/17/24 document that a home health nurse was present for wound care, neuro assessment, and a medication reconciliation. Notes document that (R1) is having "hallucinations, agitation and crying, especially during the night".



*cont on 9099AC-2...
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240702083338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNRISE VILLAGE LLC, THE
FACILITY NUMBER: 345920136
VISIT DATE: 10/22/2024
NARRATIVE
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9099AC-2... Home Health notes from 6/17/24 also document that two home health medical staff observed bruising on resident's bilateral upper extremities. Home health notes from 6/25/24, document that all the bruising appeared to have healed.

Resident stated to LPA during an interview that she recalls having a bruise on her face and staff applying creme, but didn't know how it happened. Resident also stated that there were two female staff who worked as caregivers and "one staff was rough and one staff was gentle", especially while being provided incontinent care. Resident showed LPA how when one staff asked her to "turn to the right", her left hand would hit the wall and cause her pain.

Resident's record review showed she had a hospital bed with half bed rails that was delivered shortly after she moved in. House Manager stated that resident would resist care being provided and would "fight the caregivers" and bumped her arms and possibly cheek on the rails.

Photo documentation of the bruising was not provided to the Department, and there was no evidence that home health staff had contacted the physician to evaluate the bruises.

The House manager stated that staff (S2) worked with her for many years and she has observed her to be rough with residents, and (S1) was very sweet and was singing a lot of the time.

Based on documentation reviewed and interviews conducted, LPA finds it to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


Exit interview. Copy of report provided to the Administrator.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5