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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:39:21 PM


Document Has Been Signed on 09/01/2023 03:39 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: 32DATE:
09/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Carolyn Appeal, Health Service DirectorTIME COMPLETED:
03:55 PM
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On 9/1/2023 at 2:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 8/23/2023. LPA met with Health Service Director, Carolyn Appeal and explained the purpose of the visit.

LPA received death report on 8/23/2023 for resident (R1). Death report revealed that R1 passed away at the hospital on 8/18/2023. R1 was sent to the hospital on 8/7/2023 due to respiratory distress.

LPA interviewed staff and obtained R1's documents (physician's report, care plan, and care notes). LPA was informed that R1 sent out to the hospital on 8/7/2023 due to low oxygen level. Facility staff followed up with the hospital after R1 was admitted. Care notes indicated that R1 was tested positive at the hospital on 8/7/2023 and was admitted to ICU with diagnosis of respiratory failure. Physician's report dated 4/25/2023 indicated that R1's diagnosis include COPD and atrial fibrillation.

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: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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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