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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601336
Report Date: 12/10/2021
Date Signed: 12/10/2021 02:44:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNRISE PRIVATE CAREFACILITY NUMBER:
015601336
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:3234 EAST AVENUETELEPHONE:
(925) 449-0426
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 6DATE:
12/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Telesha Clarke, AdministratorTIME COMPLETED:
02:55 PM
NARRATIVE
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On 12/10/2021 at 12:58PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 11/26/2021. LPA met with staff, Anna Horvath. Administrators, Telesha Clarke arrived 10-20 minutes later.

Incident report dated 11/25/2021 revealed that police called facility at 4:45AM to inform staff that R1 was found outside of the facility. At 5:08AM, EMT arrived to take R1 to the local hospital. R1 returned to the facility at 10:15AM.

Interview with staff revealed that R1 can turn off the door alarms and left the facility in the morning of 11/24/2021. S3 stated that R1 have not left the facility at night before and this was the first time. R1 has left the facility during the daytime, but staff observe R1 and able to redirect R1 if needed. R1 is moving out on 12/15/2021.

During record review, LPA observed that physician's report dated 8/31/2021 stated that R1 cannot leave the facility unassisted.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SUNRISE PRIVATE CARE
FACILITY NUMBER: 015601336
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2021
Section Cited

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Care of Persons with Dementia. ...Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia...require awake night supervision.
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This requirement was not met as evidence by: Based on interviews, licensee did not comply with the section cited above by not having an awake night staff which poses an immediate health and safety risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021
LIC809 (FAS) - (06/04)
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