435201400-1-10-2025-26-AS-KHOS-DD4NXU-20250120095143

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201400
Report Date: 01/10/2025
Date Signed: 01/10/2025 01:53:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/05/2024 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241205094700

FACILITY NAME:	SUNNY ORCHARD PLACE		FACILITY NUMBER:	435201400
ADMINISTRATOR:	THERESA CARR		FACILITY TYPE:	740
ADDRESS:	1155 POME AVENUE		TELEPHONE:	(408) 737-2474
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	6	CENSUS: 6	DATE:	01/10/2025
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Luisa Regala		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Caregiver hit resident on the thighs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On January 10, 2025, at 12:40 PM Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Complaint Investigation visit. Upon arrival, the LPA was greeted by the DSP, Luisa Regala. The LPA disclosed the purpose of the inspection. The DSP informed the LPA that there were (6) residents in care.

Regarding the allegation “Caregiver hit resident on the thighs”, the Reporting Party (RP) stated “On 11/22/2024 the resident reported to the complainant that caregiver Kanalle, last name unkonwn, has hit him on his thighs for the past 6 months while providing care to him. The resident stated to the RP, "Kanalle is always rough with me".

LPA interviewed (3) Residents (R1-R3). R1 was observed to be in their private room. R1 stated that S1 was rough with them, and about a week ago, the facility corrected this by removing S1 as the primary caregiver.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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 2

Control Number 26-AS-20241205094700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNNY ORCHARD PLACE	FACILITY NUMBER: 435201400
	VISIT DATE: 01/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 stated that care was good now and had no further complaints and nothing to share. R2 stated that they liked all the caregivers and showed a thumbs-up sign when asked about the quality of care provided. R3 was not able to provide anything about S1.

LPA interviewed (3) staff members (S1, S2, and S3). S1 stated they had challenges when providing care to R1 due to their yelling. R1 was in pain when S1 wiped their back and was not rough. S1 stated that they reported to their manager that it was rough for R1 when they wiped their back and needed (2) caregivers to bathe R1 and for R1’s other care needs. S2 stated that R1 is scared to turn by themselves and R1 shouts when they turn them. It was R1’s behavior to shout. S2 stated that R1 was itchy, and sensitive to touch and yells staff was hurting them when they touched R1. The staff was gentle with R1 when R1 was in pain. S2 stated that S1 was now paired with other staff members when providing care to R1.

LPA interviewed (1) family member (FM). FM stated they are aware of R1’s behavior and R1 would scream when someone would touch R1. R1 scratches themselves aggressively and that’s why R1 screams when staff touches R1. FM is working with a doctor to resolve R1’s excessive scratching. FM stated that the facility had made changes so that R1 was not alone with S1. FM was happy with the care provided to R1 at the facility and had no negative remarks.

LPA observed R1 shouting in pain when S1 and S2 were in R1’s room to change R1’s diaper. LPA interviewed R1 after the diaper change and R1 stated they had no complaints and S1 didn’t provide direct care to R1, S1 was in the room assisting S2.

LPA reviewed the facility record of the Plan of Action. S1 will not be with R1 alone for now. S1 was given Elder Abuse Training on 12/10/2024. The facility will check on R1 every day for any bruises or scratches.

Based on LPA’s observations, interviews that were conducted, and record review(s), the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation(s) is found to be UNSUBSTANTIATED.

No deficiencies were cited during today's visit.

An exit interview was conducted. A copy of this report was left with the DSP, Luisa Regala, whose signature on this form confirms receipt of the report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2