405802274-9-20-2023-29-AS-KBUY-CW5UGL-20230929153432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802274
Report Date: 09/19/2023
Date Signed: 09/20/2023 07:54:33 AM

Unsubstantiated

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
08/11/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20230811115904

FACILITY NAME:	SUNRISE TERRACE RCFE I		FACILITY NUMBER:	405802274
ADMINISTRATOR:	INGAN, EDWIN		FACILITY TYPE:	740
ADDRESS:	1135 OCEANAIRE DRIVE		TELEPHONE:	(805) 544-0982
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Licensee Edwin Ingan		TIME COMPLETED:	03:16 PM

ALLEGATION(S):

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Licensee neglect resulted in resident developing pressure injuries.
Staff handled resident in a rough manner.
Staff did not meet resident's hygiene needs.

INVESTIGATION FINDINGS:

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At 1:15pm on 09/19/2023, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA met with Licensee Edwin Ingan and explained the reason for the visit.
On 08/11/2023, the Department received a complaint regarding allegations of neglect and physical abuse of Resident #1 (R1). It was alleged that on 08/09/2023 facility staff neglected Resident #1 (R1) resulting in Stage 2 pressure injuries; handled R1 in a rough manner; and staff did not meet resident’s hygiene needs. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Ruben Munoz.
On 08/14/2023, between 10:00am and 12:15pm, Licensing Program Analyst (LPA) Mark Jeffries conducted an unannounced initial 10-day complaint investigation which included a health and welfare check visit. LPA Jeffries met with Licensee/Administrator Edwin Ingan, who arrived at the facility at 11:02am, and explained the reason for the visit.
CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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 3

Control Number 29-AS-20230811115904

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: 09/19/2023

NARRATIVE

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The LPA took a cursory tour of the facility, conducted resident and Licensee interviews, and collected documents pertinent to the investigation. The LPA determined further investigation was required.
Investigator Munoz conducted interviews on 08/15/2023, at approximately 3:37pm, with hospice personnel; and on 08/16/2023, from approximately 9:50am to 10:48am, with residents, including R1, and staff. In addition, the investigator reviewed hospice medical records, facility file documents related to R1, and staff personnel records.
R1’s Physician Report, dated 03/21/2023, noted R1’s primary diagnosis as cellulitis right buttock. Secondary diagnoses listed as diabetes type 2, hypertension, anemia, heart failure, hyperlipidemia, hypothyroidism and osteoarthritis. R1 was admitted to the facility on 03/27/2023.
According to the hospice medical records, R1 began receiving hospice services on 04/17/2023. R1 was placed on hospice with a diagnosis of recurrent sepsis. R1 has a history of recurrent E Coli UTIs. R1 is bedbound and requires use of a Hoyer lift for any transfers, and assistance for all activities of daily living except feeding. The records also indicated R1 has a stage 2 coccyx wound. The diagnoses and conditions listed in the records also included bacteremia, chronic kidney disease, type 2 diabetes, morbidly obese, and stage 2 pressure ulcer on sacral region. According to the clinical notes, R1 sometimes refused to eat, refused or was hesitant to take medication, and continued to have episodes of restlessness and agitation at night into the early morning hours. Additionally, the notes document that due to R1’s size, it is difficult for R1 to be moved in the bed without causing some discomfort.
On the allegation: Licensee neglect resulted in resident developing pressure injuries. On 08/09/2023, a witness (W1) observed a closed pressure injury on R1’s coccyx area. W1 did not observe any pressure injuries to R1’s ear or elbow. The hospice notes document that the hospice nurse was treating R1’s wounds to coccyx Stage 2, left elbow Stage 1, and left ear Stage 2. The notes dated 08/07/2023 documented the wounds were healed and wound care was discontinued. On 08/10/2023, the notes indicated no specific changes were made to the current care plan and no new wounds were noted. Based on the information obtained, the Department did not find sufficient evidence to substantiate the allegation, therefore, the allegation “Licensee neglect resulted in resident developing pressure injuries” is unsubstantiated at this time.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230811115904

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: 09/19/2023

NARRATIVE

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On the allegation: Staff handled resident in a rough manner. The investigation revealed a witness (W1) visited the facility on 08/09/2023 and observed the staff reposition R1 in a rough manner. W1 witnessed R1 being repositioned suddenly and without warning. The investigation revealed that due to R1’s size, it is difficult to move and reposition R1. R1 requires two staff to assist in repositioning and transfers. R1 was interviewed and did not have any complaints about the facility or the staff. R1 denied ever being injured or handled rough by staff. Staff were interviewed and denied handling R1 in a rough manner. Based on the information obtained, the Department did not find sufficient evidence to substantiate the allegation, therefore, the allegation “Staff handled resident in a rough manner” is unsubstantiated at this time.

On the allegation: Staff did not meet residents’ hygiene needs. It was alleged on 08/09/2023 W1 observed R1 had feces between their buttocks. R1 required assistance with toileting and/or brief changes. IB investigator observed the residents and facility were clean on 08/16/2023. LPA observed residents were clean on 08/14/2023 and 09/19/20223. Resident interviews on 08/14/2023 revealed that R1, R2, R3 and R4 denied any unmet needs including help with hygiene issues at any time. Staff interviews of S1, S2, and S3 on 08/14/2023 revealed that staff attended to all resident as needed and address all hygiene needs of residents in care. Based on the information obtained, the Department did not find sufficient evidence to substantiate the allegation, therefore, the allegation “Staff did not meet resident’s hygiene needs” is unsubstantiated at this time.

Exit interview conducted, a copy of this report issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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