Sunrise Terrace RCFE V

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Allegation investigated: The facility is not kept clean, sanitary or in good repair.

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Edwin Ingan, Administrator and explained the purpose of the visit. LPA requested a staff roster, a resident roster, and staff schedule for August 2025. LPA took a tour of the inside of the facility. LPA took photographs. The following was noted: On the allegation: The facility is not kept clean, sanitary or in good repair. LPA took photographs of the hallway and bathroom areas in the facility. A witness reported that on 08/05/2025 the hallway and bathroom were dirty and in need of repair and new paint. The witness had already reported the need to the Administrator of the facility about 3 weeks prior and nothing had been taken care of. LPA observed the hallway and the bathroom to be painted but over scratched areas made by wheelchairs with paint, the paint does not match the prior paint color leaving it to look dingy throughout the facility. Cont. 9099-C Substantiated The bathroom looks clean and sanitary and in good repair other than needing new paint on the far wall. LPA spoke with the Administrator which revealed the facility needs painting, they have called a painter to come out to give us an estimate, and the facility will be painted soon. The facility had staff 1 (S1) go around with paint and painted the scratched areas. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 29-AS-20250809093436

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 22, 2025

(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on witness and LPA observation, the licensee did not comply with the regulation above the facility hallway and bathroom were not kept in good repair and in need of painting which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: The administrator agreed to paint the facility hallways, bathrooms and any areas that need to be painted, to keep the facility in good repair. Review regulation 87303 and make sure the facility is following the full regulation. Provide pictures of the facility hallways, bathrooms, and walls once painted to CCL.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 10:16 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Edwin Ingan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has enough PPE for 30 plus days, The facility trains on infection control and PPE. Meal and medication can be delivered to rooms if a resident is in need of isolation. Physical Plant & Environmental Safety: The facility has 3 bedrooms and 2 bathrooms currently occupying 6 residents and employs 5 staff. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has a smoke alarms and the carbon monoxide detector were tested and working. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skids flooring ormats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents and locked in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and front yard for resident use with shade. The facility has telephone and internet service for resident use. The facility provides resident with a shared tablet for access internet. Operational Requirements: The facility has current liability insurance and expires on 10/28/2025. The facility is approved for a capacity of 6 non-ambulatory of which 1 may be bedridden, and Hospice approved for 3 residents. Continued 809-C Personnel Records & Training: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had current 1st Aid/CPR for all 5 staff, all other record documentation was on file. Administrator certificate expires 12/26/26. LPA reviewed 5 staff training records for 2024-2025 Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training, all staff completed required training. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for required records. All records are up to date. The admission agreements are signed, the facility has Personal Rights, Consent forms and safe guard for property and valuables. The Facility does not handle cash resources for the residents in care. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical & Dental: The facility has a locked medication cart in the dining room. Facility assists in locating transportation to medical and dental appointments when needed. Medication records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cart for all prescription and PRN medications with doctors’ orders. No medications labels were altered, and no medications were expired and medication were stored in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 12/19/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The facility has a battery backup solar system for emergencies. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility currently has 1 resident using oxygen. The facility currently has 3 residents on hospice and plans are kept up to date. The facility does not currently have any residents on Home Health services. The facility has exiting door alarms for the safety of residents in care. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 15, 2025

Allegation investigated: Staff did not meet a resident's catheter needs while in care Staff did not address a change in a resident's medical condition

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 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. 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. 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.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 29-AS-20240702084722

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87609(b)(2) · Plan of correction due date: Nov 1, 2024

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: (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 inthe state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: 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. 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87611(c) · Plan of correction due date: Nov 1, 2024

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, 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 contactedthe state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: 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. when residents foley catheter was not draining, resident was aggitated, and abdomen was distended.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 10:16 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Edwin Ingan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Physical Plant & Environmental Safety: The facility has 3 bedrooms and 2 bathrooms currently occupying 4 residents and employs 5 staff. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has a smoke alarm and discovered the carbon monoxide detector is not working properly, LPA will be sent image of new plugged in detector by close of business. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skids flooring. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents and locked in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and front yard for client use with shade. The facility has telephone and internet service for resident use. The facility provides resident with a shared tablet for access internet. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 01/5/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The facility has a battery backup solar system for emergencies. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility currently has 1 resident using oxygen. The facility currently has 1 resident on Home Health services. Home Health services records are kept on file. The facility has exiting door alarms for the safety of residents in care. Exit interview conducted and copy of report printed for Administrator. Operational Requirements: The facility has current liability insurance and expires on 10/28/2024. The facility is approved for a capacity of 6 non-ambulatory of which 1 may be bedridden, and Hospice approved for 3 residents. Personnel Records & Training: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 4 staff files. Files reviewed had current 1st Aid/CPR for all 4 staff, all other record documentation was on file. Administrator certificate expires 12/26/24. LPA reviewed 4 staff training records for 2024 Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training, all staff completed required training. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for required records. All records are up to date, a TB record will be emailed to LPA for 1 resident who arrived from separate facility and results were not included. The Facility does not handle cash resources for the residents in care. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical & Dental: The facility has a locked medication cart in the dining room. Facility assists in locating transportation to medical and dental appointments when needed. A sampling of medication records was reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cart for all prescription and PRN medications with doctors’ orders. No medications labels were altered, and no medications were expired. Continued 809-Cthe state’s words, verbatim · CDSS document, Oct 24, 2024