Sunray Healthcare Center in Los Angeles: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH made an unannounced visit on January 2, 2026 to investigate the death of Resident 1, a 70-year-old man with dysphagia (difficulty swallowing) who was on a pureed diet and was at risk for aspiration (food entering the airway). CDPH found that around 1 PM on December 31, 2025, a visitor of his roommate gave him a chocolate chip cookie while he was in bed. The department determined staff did not check food brought from outside, did not supervise him for choking while eating, and had not taught visitors to clear outside food with staff before sharing it.

The citation states the visitor saw Resident 1 shaking, choking and pale and called for help. CNA 1 found him unresponsive with food coming from his mouth. A restorative assistant performed the Heimlich maneuver, and staff moved him to a folding metal chair. Inspectors found LVN 1, CNA 1 and the restorative assistant did not check his pulse or breathing and did not start CPR, although he was a full code (his POLST form called for CPR). A respiratory therapist found no pulse and told staff to put him back in bed for CPR. The facility called 911 at 1:20 PM, and paramedics declared him dead at 1:34 PM.

CDPH issued a Class AA citation with a $100,000 penalty. The federal 2567 report cites F678 (CPR) at severity J and F689 (accident hazards and supervision) at severity J. According to the 2567 report, inspectors called an Immediate Jeopardy on January 7, 2026. The facility's removal plan included CPR training and certification for all nurses, CPR drills, keeping nurses without a CPR card off the schedule, and an audit of 80 residents' charts.

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Inspectors found the facility did not give Resident 39, who had major depressive disorder, the behavioral health care he needed. According to the 2567 report, staff did not monitor him for sadness and signs of depression as his care plan required, did not arrange for a psychiatrist or psychologist to evaluate his mood, and did not check whether his care plan was working. A questionnaire on October 21, 2024 recorded that he felt down or hopeless nearly every day. On October 28, he told an inspector the facility was not doing enough to help him get better and began to cry. The report states LVN 1 said he was not being monitored for a mood problem, and the social services director confirmed he was not monitored and had not seen a psychiatrist or psychologist.

The 2567 report also states that on October 28, 2024, Resident 77, who needed substantial help with hygiene, called out for about 45 minutes asking to have her incontinence brief changed. Inspectors saw a CNA tell her "give me one moment" and saw LVN 3 not respond. She told inspectors she had been sitting in urine and feces and felt dirty, unimportant and frustrated. LVN 3 said her assigned CNA was at lunch. Inspectors also found Resident 48 with dry, flaky matter around his right eye from the night before, although his care plan called for daily eye cleaning.

According to the report, the findings were cited under F740 (behavioral health services) at severity G and F600 (free from abuse and neglect) at severity G.

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According to the 2567 report, Resident 1 was admitted in August 2023 after a traumatic brain bleed, depended on staff for all daily care, and was assessed as high risk for pressure sores (bed sores, skin injuries over bony areas caused by long pressure). Resident 1 arrived with a deep tissue injury at the base of the spine. His care plan and a care conference called for turning and repositioning the resident at least every two hours.

Inspectors found the facility did not make sure staff turned and repositioned Resident 1 every two hours and as needed, as the physician's order and facility policy required. The report states nursing notes did not show repositioning on many dates in September, October and December 2023, and some dates had no nursing notes at all. By December 2023, the wound at the base of the spine was a Stage 4 pressure sore (the deepest stage), and a wound doctor removed dead tissue. An order for a low air loss mattress was discontinued in January 2024.

The 2567 report states Resident 1 developed five new pressure sores that were not present on arrival, including on both ears, the right foot and the left ankle. Inspectors cited F686 (treatment and services to prevent and heal pressure ulcers) at severity G.

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The 2567 report states Resident 1 was admitted on February 29, 2024 from a hospital, where he had been treated for kidney failure and septic shock, and he still needed dialysis (a treatment that filters waste from the blood). According to the report, he had told several staff members he wanted to leave. Around midnight on March 3, 2024, staff found he had eloped (left without staff knowledge). Inspectors found the facility did not know how or when he left and had not found him. The report states he faced an increased risk of serious harm or death from missing dialysis and medications.

Inspectors found the facility did not assess Resident 1's elopement risk on admission, did not carry out care plan steps to check his whereabouts, did not tell staff about planned checks every 30 minutes, did not treat his repeated requests to leave as a sign of elopement risk, and did not follow its own wandering and elopement policy.

According to the report, the deficiency was cited under F689 (accident hazards, supervision and devices) at severity J. Inspectors called an Immediate Jeopardy on March 11, 2024 and removed it on March 13 after confirming the facility's removal plan was in place. The plan included staff training on elopement, elopement drills, reassessing all residents, visual checks every 30 minutes for 72 hours for residents found at risk, elopement assessments within 24 hours of admission, and weekly audits by medical records staff.

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According to the citation, CDPH made an unannounced visit on January 12, 2024 to investigate a complaint about Resident 1, who was confused, had an unsteady gait, used a wheelchair, and had been assessed as a high fall risk. He had Parkinson's disease and right-side weakness from a prior stroke. CDPH found he had unwitnessed falls on August 20, September 5, September 27 and November 19, 2023. Post-fall reviews for two of those falls left the root cause section blank, and the fall care plan was not updated after the third fall.

CDPH found the facility did not supervise Resident 1 while he moved around the building unattended in his wheelchair and did not identify interventions aimed at his specific risks. On November 23, 2023, at 2 PM, he had a fifth unwitnessed fall and was found face down in his room, bleeding from the right side of his head. Paramedics took him to a hospital, where he was diagnosed with a traumatic brain injury (an injury from a blow to the head), bleeding around the brain and a 3 cm cut on his forehead. The 2567 report states he was admitted to the trauma intensive care unit, the bleeding could not be treated with surgery, and a physician later noted he kept his eyes closed and did not respond to stimuli.

CDPH issued a Class A citation, and the citation lists a $20,000 penalty trebled to $60,000. CDPH records list the citation as appealed, with a final amount due of $55,000. The federal 2567 report cites F689 (accident hazards, supervision and devices) at severity G.

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According to the 2567 report, Resident 77 had a diagnosis of HIV (a virus that attacks the immune system). Inspectors found the facility did not reassess him for a weakened immune system, did not hold an interdisciplinary team meeting about his HIV status, and did not develop or carry out a care plan for it. The report states he did not receive HIV-related medical care, including HIV medications.

Inspectors found that by November 30, 2023, his CD4 cells (immune cells the virus attacks) had dropped below the normal range, to 29%, and his HIV viral load had risen to 148,339 copies per milliliter. The 2567 report states this raised the chance he could get life-threatening opportunistic infections, which could lead to hospitalization or death.

The deficiency was cited under F684 (quality of care) at severity J. According to the report, inspectors identified an Immediate Jeopardy on November 30, 2023, and it was removed on December 2 after the facility submitted an acceptable removal plan. The plan included a physician evaluation and blood tests for Resident 77, a care conference with his responsible party, a new care plan coordinated with an outside clinic, audits of residents with recent changes in condition and of new admissions, and training for licensed nurses on identifying and reporting changes in condition.

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According to the citation, CDPH made an unannounced visit on April 19, 2023 to investigate a facility-reported incident involving falls by Resident 1. He had Parkinson's disease and another neurological disorder that affects walking and balance, and the facility had identified him as a high fall risk. CDPH found the facility did not identify and use new or different interventions to prevent more falls, did not carry out interdisciplinary team recommendations, did not place him on one-to-one supervision, and did not follow a nurse practitioner's orders for a safety helmet and knee and elbow pads.

The department found Resident 1 fell three times in April 2023. On April 4, he was found next to his bed and sent to a hospital with facial abrasions (scrapes), a collection of blood on the right side of his head and a nosebleed. On April 6, he fell out of a wheelchair and scratched his eyebrow. On April 12, he fell from bed face down. According to the citation, a hospital admitted him to intensive care with bleeding under the scalp and around the brain, a skull fracture, a LeFort II facial fracture (broken bones in the middle of the face) and neck fractures.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689 (accident hazards, supervision and devices) at severity G.

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According to the citation, CDPH made an unannounced visit on December 17, 2022 to investigate a complaint that services were not performed as the physician ordered. Resident 1 was admitted in October 2019 with quadriplegia (paralysis from the neck down) and depended on a ventilator. Resident 1's admission records did not show contractures. In November 2019, a physician ordered a daily restorative program of passive range-of-motion exercises (staff move the joints for the resident) for both arms and legs.

CDPH found the facility did not provide the passive range-of-motion exercises to both arms on many dates between June 2020 and August 2021, a total of 13 months, and restorative flow sheets for those dates were blank. The department also found staff did not apply the hand and elbow splints the occupational therapist recommended for more than one year and seven months after therapy ended in May 2021. According to the citation, the range of motion in both of Resident 1's arms declined further and the resident developed contractures (permanent joint stiffness and deformity) that interfered with daily care.

CDPH issued a Class A citation with a $25,000 penalty, finding the facility failed to protect the resident's right to be free from neglect. The federal 2567 report cites F600 (free from abuse and neglect) at severity G and F688 (range of motion and mobility) at severity G.

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