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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802278
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:02:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
07/02/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20240702084722
FACILITY NAME:SUNRISE TERRACE RCFE VFACILITY NUMBER:
405802278
ADMINISTRATOR:GREGORIO, ALBERTFACILITY TYPE:
740
ADDRESS:2117 DEL NORTETELEPHONE:
(805) 534-0808
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 4DATE:
10/31/2024
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Edwin InganTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not meet a resident's catheter needs while in care
Staff did not address a change in a resident's medical condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Edwin Ingan and explained the purpose of the visit. During the initial visit on 7/9/24 from 12:15 pm to 2:15 pm, LPA Rankin toured the facility interviewed staff and obtained relevant documents. Additional interviews were conducted with relevant parties on 7/9/24 and 10/17/24.

On the allegations: Staff did not meet a resident's catheter needs while in care and staff did not address a change in a resident’s medical condition. It was alleged on 6/26/24 Resident 1 (R1) had an issue with a foley catheter (f/c). It was alleged that staff was not monitoring urine collection bag and staff did not notify Home Health of R1’s symptoms.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
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 6
Control Number 29-AS-20240702084722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SUNRISE TERRACE RCFE V
FACILITY NUMBER: 405802278
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2024
Section Cited
CCR
87609(b)(2)
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87609 Allowable Health Condition and the Use of Home Health Agencies (b) Incidental medical care may be provided ...through a licensed home health agency provided the following conditions are met:

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Licensee agrees to review section 87623 Indwelling Urinary Catheter in entirety and submit a signed statement of understanding. Will also ensure R1’s Home Health binder is up to date, including adding the documented training and written procedures.
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(2) ...licensee provides the supporting care and supervision needed to meet the needs of the resident...Based on interview, and records reviewed licensee did not comply with the regulation above in
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that resident was assessed by Home Health and documented that resident had an empty foley catheter bag, with signs and syptoms of pain, restlessness and aggitation due to urine not draining.
Type A
11/01/2024
Section Cited
CCR
87611(c)
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87611 General Requirements for Allowable Health Conditions (c) ...facility staff shall have knowledge and the ability to recognize and respond to problems and shall contact the physician,
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Licensee agrees to hold training with all staff about recognizing and responding to change in condition, signs and symptoms, and the procedure for timely notifying medical professionals. Licensee will provide proof of training by 11/1/24.
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appropriately skilled professional, and/or vendor as necessary. Based on interviewes, and records reviewed licensee did not comply with regulations in that Home Health was not contacted
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when residents foley catheter was not draining, resident was aggitated, and abdomen was distended.
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: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20240702084722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE V
FACILITY NUMBER: 405802278
VISIT DATE: 10/31/2024
NARRATIVE
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An interview on 7/9/24 Licensee stated R1 is uncooperative with staff when they want to drain the catheter bag, staff will leave R1 and return a little later to try again. It was stated caregivers try to check bag every 1-2 hours. Licensee stated nurse told staff the tube was “kinked” and that is why it was not draining.

Interview with S2, S2 stated the morning of 6/26/24 R1 was agitated and when they touched R1’s stomach they noticed there was pain. Staff informed F1 of the agitation, and f/c not draining. S2 believed that F1 would call and inform Home Health of the change of condition. Facility staff now understand to call Home Health directly with change of condition and will notify family as well.

During scheduled Home Health visit on 6/26/24, Home Health documented the following: that R1 had “increase anxiety and agitation”. “…f/c appears to be intact, however is not draining any urine and f/c drainage bag is empty. F/C balloon was deflated, and f/c was removed…new f/c was inserted with return of dark grey and yellow cloudy/milky colored urine.” “…1200cc of urine was drained from patient’s bladder within 15 minutes.” “When abdomen is palpated, patient hollers out in pain, and when f/c is removed, patient yells out in pain. Once f/c is changed, patient has no further complaints or signs /symptoms of pain.” “Abdomen is distended and firm and painful with palpitation per patient.” “Staff unaware there was no urine draining into f/c drainage bag”. Notes on 6/26/24 are the first notes where R1’s pain is noted.

Prior notes provide the following history: 3/19/24 from Home Health Nurse 1 (HH1) states Home Health Staff 2 (HH2) “is finishing treatment as I arrive today. [HH2] informs me that the staff at the RCFE do not know how to manage [R1’s] catheter, and it keeps pulling loose the way the staff is managing it.” 3/19/24 HH2 notes, “Teaching was provided to Family Member 1 (F1) and Staff 2 (S2) as neither knew how to properly place these devices…S1 and [F1] Verbalized Understanding of all education provided today.” On 4/27/24 – “R1 continues to “mess” with [R1] f/c and drainage bag…Upon assessment of f/c, it is noted that patient f/c bag is placed to posterior leg versus anterior leg and each time patient rests leg against something, the clasp of the drainage bag pops open thereby causing leaking. It is also noted that the leg strap securing patients f/c is placed too low on the thigh which is causing the f/c to pull which might be irritating or painful to patient.”

In interview with Licensee conducted on 7/9/24 and during annual visit on 10/24/24, LPA inquired about training documents specific to home health requests.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20240702084722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE V
FACILITY NUMBER: 405802278
VISIT DATE: 10/31/2024
NARRATIVE
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Licensee stated that if the care is something the staff are familiar with, there is no training needed and that no training was done by Home Health. No training documents regarding catheter care were provided to the LPA from the facility during both visits. Review of Home Health chart notes show on the following dates staff were provided training and expressed understanding of training: Regarding Instruction on Indwelling foley catheterization/care, UTI, Signs and Symptoms 2/2/24, 2/7/24, 2/27/24, 3/13/24, 3/28/24, 4/27/24, 4/30/24, 5/8/24, 5/29/24, 6/12/24, 6/26/24. Notes state verbal instructions given to Patient Caregiver (PCG). PCG Understanding demonstrated by verbalization.

Due to the continued training conducted with staff, a note was observed on the wall by R1’s bed stating “If pt is complaining of pain or showing symptoms of pain such as restlessness, agitation, moaning, grimacing or combativeness, check foley catheter and foley catheter drainage bag for urine draining appropriately. Check abdomen for distention, firmness, and tenderness. Monitor fluid intake and urine output. Remember what goes in should come out. Notify [Home Health] for concerns immediately.”

Based on the investigation, staff failed to notice or report to Home Health that R1’s foley catheter bag was empty on at least one occasion, despite documented training to staff and R1 expressing symptoms.

Based on LPAs interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulation, Title 22, 87609(b)(2) and 87611(c) are being cited on the attached LIC 9099D. Title 22 regulations 87623 Indwelling Urinary Catheter was printed and provided to facility.

Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
07/02/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20240702084722

FACILITY NAME:SUNRISE TERRACE RCFE VFACILITY NUMBER:
405802278
ADMINISTRATOR:GREGORIO, ALBERTFACILITY TYPE:
740
ADDRESS:2117 DEL NORTETELEPHONE:
(805) 534-0808
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 4DATE:
10/31/2024
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Edwin InganTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident developed a pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Edwin Ingan and explained the purpose of the visit. During the initial visit on 7/9/24 from 12:15 pm to 2:15 pm, LPA Rankin toured the facility interviewed staff and obtained relevant documents. Additional interviews were conducted with relevant parties on 7/9/24 and 10/17/24.

On the allegation: Resident developed a pressure injury while in care. It was alleged due to neglect and staying in a recliner all day, R1 developed a Stage II pressure injury on their buttock.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20240702084722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE V
FACILITY NUMBER: 405802278
VISIT DATE: 10/31/2024
NARRATIVE
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R1 is non-ambulatory and uses a wheelchair, but is not bedridden. LPA observed that R1 is physically able to adjust their location and move freely. During interview conducted with Licensee on 7/9/24, it was confirmed that a small wound was noted on the left buttocks. An image of the photo was collected from the licensee as well as noted in Home Health notes.

Home Health notes for 6/26/24 states “Upon skin assessment,... wound noted to Lt buttocks which [S1] reports has been present for a few days. [S1] reports applying calmoseptine daily.”

Home Health notes show training was given to staff and instructions on Pressure relief measures, standard precautions, Signs and Symptoms of infection on 2/7/24, 2/13/24, 2/27/24, 2/29/24, 3/19/24, 3/28/24, 4/27/24, 5/8/24, 6/12/24, 6/26/24, 6/27/24. Notes state Verbal instructions given to PCG. PCG Understanding demonstrated by verbalization.

However, no notes indicated due to staff neglect, R1 developed the pressure injury, considering R1 was able to reposition self. Licensee is reminded to ensure R1’s Home Health file is up to date with all documented training and procedures.

Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview, report given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6