347004408-8-16-2024-27-AS-KHOS-D8HQ6R-20240826115357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004408
Report Date: 08/16/2024
Date Signed: 08/16/2024 03:08:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
11/20/2023 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20231120141425

FACILITY NAME:	SUNNY BEACH VILLA		FACILITY NUMBER:	347004408
ADMINISTRATOR:	DIMITROVA, DESSI		FACILITY TYPE:	740
ADDRESS:	2506 CASTLEWOOD DR		TELEPHONE:	(916) 486-4265
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	6	CENSUS:	DATE:	08/16/2024
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Dessi Dimitrova		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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1) Questionable Death.

Neglect/Lack of Supervision:
2) Staff did not ensure resident received adequate nutrition while in care.
3) Staff did not ensure resident received sufficient fluid intake while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to Sunny Beach Villa RCFE on 8/16/24 at 2:25pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Dessi Dimitrova and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the department was unable to corroborate the allegations. Per the allegation of questionable death, the department could not corroborate the allegations as the determined cause of death was determined to cardiopulmonary arrest. Department review of medical records determined alleged victim had multiple comorbidities that contributed to the resident’s cause of death. Due to the resident’s medical history and medical records, the department has determined the cause of death was not suspicious or was a result of neglect/lack of supervision by facility staff. Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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 27-AS-20231120141425

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNNY BEACH VILLA	FACILITY NUMBER: 347004408
	VISIT DATE: 08/16/2024

NARRATIVE

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Additionally, the department conducted interviews with facility staff and residents who all denied resident was not provided or denied adequate nutrition and fluid intake while in care at the facility. Residents interviewed all denied and provided statements to the department that residents were provided and encouraged to drink fluids and eat balanced nutritious meals while in care at the facility. Documentation obtained by the department indicates resident made independent choices in regard to food and fluid intake. Resident would often order and have food delivered to the facility while declining food prepared by facility staff and consumed by other residents in the home. The department has determined the allegations that the facility did not provide nutritious meals and did not provide adequate fluid intake to meet resident’s needs has been unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of questionable death and neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC9099 (FAS) - (06/04)

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