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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802274
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:01:51 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20230509145340
FACILITY NAME:SUNRISE TERRACE RCFE IFACILITY NUMBER:
405802274
ADMINISTRATOR:INGAN, EDWINFACILITY TYPE:
740
ADDRESS:1135 OCEANAIRE DRIVETELEPHONE:
(805) 544-0982
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 6DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator / Edwin InganTIME COMPLETED:
04:01 PM
ALLEGATION(S):
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Facility staff did not notify resident’s physician of change in resident’s condition.
Facility staff mismanaged resident's prescription,
Facility staff did not ensure that resident received medication as prescribed.
Facility staff falsified resident's medication record.
INVESTIGATION FINDINGS:
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 At 2:00pm on 05/19/2023, Licensing Program Analyst (LPA) arrived unannounced at the facility to issue final findings to the allegations above to this complaint. LPA met with Administrator, Edwin Ingan announced who he was and the reason for the visit.

As to the allegation of, “Facility staff did not notify resident’s physician of change in resident’s condition.” It was discovered through interviews, and documentation that Staff 1 (S1) observed R1’s leg to be swollen on 04/15/2023. LPA interview with S1 on 05/10/2023, where S1 explained that they observed R1’s swollen leg on 04/15/2023. On 04/16/2023, R1’s leg was still swollen according to S1. S1 contacted R1’s responsible party (F1) on 04/16/2023, however S1 did not contact the facility administrator or R1’s Primary Care Physician. On 04/17/2023, R1’s Primary Care Physician conducted an unannounced routine facility visit of R1. At the time of the visit, R1’s Primary Care Physician contacted F1 to take R1 to the Emergency Room, and R1 was hospitalized from 04/17/2023 through 04/20/2023.
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CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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 29-AS-20230509145340
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274
VISIT DATE: 05/19/2023
NARRATIVE
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 LPA interviewed S3, current acting administrator, on 05/10/2023. S3 stated that they were not called and had no communications of R1’s swollen leg, the contact with F1 or the Primary Care Physician visit on 04/17/2023. S3 stated that on 05/10/2023 at approximately 11:00am was the first time that they heard of R1’s change of condition and the doctor’s visit to the facility to see R1. Based on Interviews and documentation, the allegation of, “Facility staff did not notify resident’s physician of change in resident’s condition.” Is substantiated at this time.

As to the allegations, “Facility staff mismanaged resident’s prescription,” “Facility staff did not ensure that resident received medication as prescribed” and “Facility staff falsified resident's medication record.” It was alleged that the facility did not ensure R1 received a medication as prescribed, that the facility did not assist R1 in obtaining the prescribed medication from the pharmacy, and that the facility incorrectly documented R1’s medications. It was discovered through documentation and interviews that on 12/07/2023 a prescription of Medication (Med1) was filled through CVS Pharmacy on 12/07/2023 for R1. Facility Medication record provided by R1’s responsible party at time of R1’s admission to the facility on 12/16/2022, indicated that R1 had a total of 4 medications prescribed. LPA collected and reviewed facilities monthly Medication Administration Records (MAR) of R1 for the months of December 2022, and January, February, March, April, and May of 2023, which 4 of 4 medications were noted on each and all the monthly MARs, including Med1. LPA interviewed S1 and S2 on 05/10/2023, LPA asked both S1 and S2 if they recalled assisting R1 with Med1 prior to 04/10/2023 (when R1 returned from the hospital with new prescription of Med1). LPA showed physical bottle of Med1 to S1 and S2 as well as pointed out on the monthly MAR of which Medication LPA was referring to. When asked about assisting R1 with Med1, both S1 and S2 indicated that they had not assisted R1 with Med1 until 04/20/2023. Both S1 and S2 did not recall ever having Med1 at the facility until 04/20/2023 when R1 returned from the hospital. LPA asked both S1 and S2 why they initial on a daily basis for the last 6 months that the Med1 had be given to R1 on each of the monthly MARs when there was no Med1 to give, and they both state, “I don’t know”. LPA requested LIC622 Centrally Stored Medication and Destruction Record from the facility, however the facility did not have a Centrally Stored Medication Record for R1 at the time of investigation visit and again on 05/12/2023 when LPA made a phone call request for the Centrally Stored Medication inventory for R1.

CONTINUED on LIC9099-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20230509145340
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274
VISIT DATE: 05/19/2023
NARRATIVE
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Based on interviews, and documentation Med1 which was prescribed on 12/07/2022 was not provided to the facility when R1 was admitted on 12/16/2022 and not obtained until R1 returned from the hospital on 04/20/2023. The facility documented that Med1 was taken by R1 from 12/16/2022 until R1 was hospitalized on 04/17/2023, which was not accurate based admission of S1 and S2 and confirmed by R1’s primary physician and supported by results of testing from R1’s hospitalization on 04/17/2023 through 04/20/2023, therefore the allegations, “Facility staff mismanaged resident’s prescription,” “Facility staff did not ensure that resident received medication as prescribed” and “Facility staff falsified resident's medication record” are substantiated at this time.

Exit interview, report read, citations issued, appeal rights and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20230509145340
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2023
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, ... when such observation reveals unmet needs. When changes such as ... physical health condition are observed, the licensee shall ensure that such changes are
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Administrator will conduct a comprehensive 2 hour training withl all staff in all Administrators facilities on observation of residents and medication administration and documentation. Administrator will formulate training and provide staff list and training times to LPA via email by 05/22/2023.
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documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met by evidence of R1s hospitalization per Doctors visit, which put R1 in imminent danger.
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Type A
05/22/2023
Section Cited
CCR
87465(e)(A-F)
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87465 Incidental Medical and Dental Care (e) For every ...medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the
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Administrator will conduct a full medication audit of all residents in all of administrators facilities to ensure all medications are being given as prescribed. This comprehensive medication audit should start no later than 05/22/2023 and Administrator will update LPA on a daily basis by email.
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physician's order and the label shall contain at least all of the following information. (A-F information) This requirement was not met by evidence of S1 admission of not providing Med1, and then initialing Med1 MAR to indicate med was given. Which put R1 in imminent danger.
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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: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4