<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:40:36 PM


Document Has Been Signed on 04/07/2023 04:40 PM - It Cannot Be Edited

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:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:ROSE, JESSICAFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:46CENSUS: 34DATE:
04/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jacqueline Scott, Business Office ManagerTIME COMPLETED:
04:55 PM
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
On 4/7/2023 at 2:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection in regards to the two SOC341 that was received. LPA met with Business Office Manager, Jacqueline Scott.

SOC341 dated 2/9/2023 states that R1 and R2 was sitting next to each other on the couch. R1 and R2 had an altercation and R2 was back handed by R1. Staff immediately separated the two residents. Both residents' responsible party and doctors were notified.

SOC341 dated 3/30/2023 states that R3 was sitting on a wheelchair in the dining area with legs extended. R1 grabbed R3's legs and attempted to pull R3 to the floor. Staff was nearby to catch R3 and assisted R3 to the floor. Both residents' responsible party and doctors were notified.

During visit, LPA interviewed staff and reviewed R1's files. For incident on 2/9/2023, R1's family was informed and facility required 1:1 companion for the next 72 hours during the daytime. R1's doctor adjusted medication for R1. For incident on 3/29/2023, R1's family was informed and facility required 1:1 companion for the next 72 hours during the daytime. R1's medications was increased.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1