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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880681
Report Date: 08/11/2021
Date Signed: 08/11/2021 12:18:04 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2020 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200803114859
FACILITY NAME:SUNSHINE BOARD & CAREFACILITY NUMBER:
361880681
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:720 N LINDEN AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:12CENSUS: 12DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ahmad "Adam" Abdallatef - Designated Facility RepresentativeTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff are not keeping residents safe
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived to deliver findings for the allegations of the complaint. LPA Colvin met with Designated Facility Representative Adam Ahmad "Adam" Abdallatef at the facility, and spoke with Licensee over the telephone. LPA Colvin advised Adam and Licesensee of the purpose of the visit.

Regarding allegation "Facility staff are not keeping residents safe": LPA Colvin interviewed residents and staff regarding an incident that occurred between two residents (R1 & R2) in 2020, wherein R1 got into a physical altercation (restrained) with R2. Through interviews it was confirmed that the incident occurred, and that there had been numerous instances of verbal altercations between R1 and R2 prior to this event. LPA Colvin additionally reviewed the file for R1, where LPA Colvin observed that R1 was documented to have a mental illness, for which he was prescribed medication and was refusing to take. This was further documented with a Medication Administration Record (MARs) that was blank. LPA Colvin confirmed during interviews that R1 had shown signs leading up to the incident, such as acting strange and not getting along with other residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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 3
Control Number 18-AS-20200803114859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUNSHINE BOARD & CARE
FACILITY NUMBER: 361880681
VISIT DATE: 08/11/2021
NARRATIVE
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Throughout LPA Colvin's investigation, LPA Colvin confirmed that the altercation between R1 and R2 did take place and that the police were later called out and detained R1. The altercation consisted of R1 putting R2 in a head lock with their arms, pinning R2 to the wall, and taking R2 to the ground and restraining R2 there for a period of time. Through interviews conducted, LPA Colvin learned that there was no immediate staff intervention done by staff during the incident or prior as the argument between residents was escalating.
Additionally, LPA Colvin was informed that after the incident, no additional mental health treatment, assistance, or evaluation, was sought for R1 by the Administrator. During LPA Colvin's investigation, she was provided with a document which claimed to be an eviction notice for R1, which was dated for 4/29/20. However, this Eviction Notice was not carried out, as R1 did not move out of the facility until December 2020. Furthermore, no documentation of this Eviction Notice was provided to Licensing, and it was not readily available in R1's file or for LPA Colvin to review during a physical inspection of the facility and was provided to her electronically later by facility staff. Lastly, the validity of the Eviction Notice is in question as LPA Colvin interviewed outside parties in relation to R1's move from the facility, and no one interviewed other than facility staff could verify that R1 was ever given an eviction notice or asked to leave the facility.

The Licensee failed to address the physical altercation between R1 and R2 adequately by either seeking additional assistance from mental health (such as an evaluation or increase of services), knew that R1 was diagnosed with a mental health diagnosis and had been refusing medication and treatment, and failed to provide/enforce an eviction notice for R1 when R1 violated the facility's rules and posed a safety risk to other residents. Additionally, staff failed to provide adequate supervision to residents as it was reported in LPA Colvin's investigation by multiple persons that R1 was showing signs of odd behavior prior to the incident between R1 and R2, and both staff members on duty were in the kitchen cooking and not providing supervision to the residents when the altercation occurred. Based on LPA Colvin's interviews and records review, the allegation of "Facility staff are not keeping residents safe" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of this report was provided to Designated Facility Representative Adam Ahmad "Adam" Abdallatef during the exit interview, and LPA Colvin will be emailing a copy of the report to Administrator/Licensee Najeh "Nick" Hamed as well.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20200803114859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUNSHINE BOARD & CARE
FACILITY NUMBER: 361880681
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2021
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights...in...Facilities: (a) In addition to the rights...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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R1 has been relocated to another facility and there has been no further conflict. Licensee agrees in the future to keep documentation of all efforts made by the facility for prevention and follow-up to ensure residents' safety and well-being. No further Plan of Correction required.
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This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with 1 resident (R1). R1 got into a physical altercation with R2. No mental health treatment was sought or eviction notice enforced. This was an immedaite person rights violation.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3