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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200722
Report Date: 08/02/2023
Date Signed: 08/02/2023 02:03:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210824082223
FACILITY NAME:SUNRISE OF PLEASANTONFACILITY NUMBER:
019200722
ADMINISTRATOR:MALEK, MELISSAFACILITY TYPE:
740
ADDRESS:5700 PLEASANT HILL RDTELEPHONE:
(925) 416-0238
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:103CENSUS: 85DATE:
08/02/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Tracy Burke, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained a fall while in care
Facility staff did not seek medical attention in a timely manner
Facility staff do not respond to resident’s call button in a timely manner
Facility staff left resident in soiled clothing for an extended period of time
Facility staff are not following resident’s hospice plan
INVESTIGATION FINDINGS:
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On 08/02/23 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

Allegation: Resident sustained a fall while in care
Investigation Finding: Substantiated
During investigation, Witness (W1) confirmed with LPA that R1 sustained minor injuries as a result of 2 falls while in care on 08/16/21. LPA reviewed hospice report dated 08/16/21 which showed hospice nurse received communication from staff that resident (R1) sustained minor injuries from two falls inside her bedroom earlier that morning. The preponderance of evidence standard has been met and the above allegation(s) that resident sustained a fall while in care was found to be substantiated.
Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 15-AS-20210824082223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OF PLEASANTON
FACILITY NUMBER: 019200722
VISIT DATE: 08/02/2023
NARRATIVE
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Allegation: Facility staff did not seek medical attention in a timely manner
Investigation Finding: Substantiated
During investigation, LPA reviewed hospice report dated 08/16/21 wherein hospice nurse (W2) stated that she received communication from staff that R1 had fallen twice in the AM that day. Upon arrival on 08/16/21, W2 noted R1 had bruises on left face, face swollen, skin tears on hand and treated R1’s minor injuries. W1 stated that med staff on duty (S3) on 08/16/21 did not treat resident’s (R1’s) minor injuries when R1 fell twice in the morning. The department has investigated the allegation that staff did not seek medical attention in a timely manner. The preponderance of evidence standard has been met and the above allegation(s) was found to be substantiated.

Allegation: Facility staff do not respond to resident’s call button in a timely manner


Investigation Finding: Substantiated
During investigation, LPA observed resident (R1) was placed under hospice care on 06/15/2021. Review of R1’s pendant history logs show staff did not respond to resident’s call button in a timely manner (6/15/21 alarm 6PM /Staff responded & cleared alarm 6:39PM; 6/16/21 at 8:19AM/Staff responded & cleared alarm 9AM; 6/16/21 alarm at 10:55AM/Staff responded & cleared alarm 11:39AM; 6/16/21 alarm at 6PM/Staff responded & cleared alarm 7:09PM; 6/17/21 alarm at 1:35PM/Staff responded and cleared alarm 2:36PM. The preponderance of evidence standard has been met and the above allegation(s) that staff do not respond to resident’s call button in a timely manner was found to be substantiated.

Allegation: Facility staff left resident in soiled clothing for an extended period of time


Investigation Finding: Substantiated
During investigation, LPA confirmed with witness (W1) that staff left resident (R1) in soiled clothing for an extended period of time on 06/15/21 (more than 30 minutes), 06/25/21 (more than 43 minutes), 08/09/21 (more than 2 hours). Review of phone text messages dated 06/15/21, 7/06/21 and 08/09/21 between W1 and staff (S2) show staff left resident in soiled clothing for an extended period of time. The preponderance of evidence standard has been met and the above allegation(s) that staff left resident in soiled clothing for an extended period of time was found to be substantiated.
Continued on next page, LIC 9099-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 15-AS-20210824082223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OF PLEASANTON
FACILITY NUMBER: 019200722
VISIT DATE: 08/02/2023
NARRATIVE
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Allegation: Facility staff are not following resident’s hospice plan
Investigation Finding: Substantiated
During investigation, LPA reviewed phone text messages between witness (W1) and staff (S2) dated 08/09/21, 08/18/21, 08/20/21, 08/21/21 which showed staff failed to reposition R1 every 2 hours. The preponderance of evidence standard has been met and the above allegation(s) that staff are not following resident’s hospice plan was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proofs of correction (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 15-AS-20210824082223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OF PLEASANTON
FACILITY NUMBER: 019200722
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
08/02/2023
Section Cited
CCR
87465(a)(1)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Deficiency cleared during visit.

Administrator completed and submitted to LPA staff re-training certifications regarding fall prevention care protocols dated 09/08/2021.
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This requirement was not met as evidenced by resident sustaining a fall while in care which posed a potential health & safety risk to resident in care.
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Deficiency Dismissed
Type B
08/02/2023
Section Cited
CCR
87465(j)
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In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed with self-administration of medications. The names of the staff employees so responsible and the designated procedures shall be documented and made known to all residents and staff.
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Deficiency cleared during visit.

Administrator completed and submitted to LPA staff re-training certifcations on proper medical and dental care dated 09/08/2021.
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This requirement was not met as evidenced by staff not timely seeking medical attention to resident which posed a potential health & safety risk to resident 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 15-AS-20210824082223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OF PLEASANTON
FACILITY NUMBER: 019200722
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2023
Section Cited
CCR
87468.2(a)(4)
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…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Deficiency cleared during visit.

Administrator completed and submitted to LPA staff re-training certifications on timely responses to call button, pull cord alerts dated 09/08/2021.
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This requirement was not met as evidenced by staff not responding to resident's call button which posed a potential health & safety risk to residents in care.
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Deficiency Dismissed
Type B
08/02/2023
Section Cited
CCR
87465(a)(2)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs.
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Deficiency cleared during visit.

Administrator completed and submitted to LPA staff re-training certifications on proper incontinent care dated 09/08/2021.
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This requirement was not met as evidenced by staff leaving resident in soiled clothing for an extended period of time which posed a potential health & safety risk to resident 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 15-AS-20210824082223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OF PLEASANTON
FACILITY NUMBER: 019200722
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2023
Section Cited
CCR
87633(a)(4)
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(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).
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Deficiency cleared during visit.

Administrator completed and submitted to LPA staff re-training certifications on proper implementation of hospice care plans dated 09/08/2021.
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This requirement was not met as evidenced by staff not following resident's hospice care plan which posed a potential health & safety risk to resident 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210824082223

FACILITY NAME:SUNRISE OF PLEASANTONFACILITY NUMBER:
019200722
ADMINISTRATOR:MALEK, MELISSAFACILITY TYPE:
740
ADDRESS:5700 PLEASANT HILL RDTELEPHONE:
(925) 416-0238
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:103CENSUS: 85DATE:
08/02/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Tracy Burke, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff is not safeguarding resident’s personal property
Facility staff did not ensure that resident is taking medications as prescribed
Facility staff did not treat resident with dignity
INVESTIGATION FINDINGS:
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On 08/02/23 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

Allegation: Facility staff is not safeguarding resident’s personal property
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed resident’s (R1) signed personal property and valuables document dated 06/27/2018. Missing items reported by witness (W1) such as a blanket, bracelets, groceries were not listed in the personal property/valuables entrusted to the facility nor were there any signed addendums completed accounting for these additional personal belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff is not safeguarding resident’s personal property is unsubstantiated.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 15-AS-20210824082223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OF PLEASANTON
FACILITY NUMBER: 019200722
VISIT DATE: 08/02/2023
NARRATIVE
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Allegation: Facility staff did not ensure that resident is taking medications as prescribed
Investigation Finding: Unsubstantiated
During investigation, ADM stated resident (R1) was admitted into hospice care on 06/15/21 due to declining health. Prior to being admitted into hospice care, R1 was managing her own medications. On 06/16/21, staff obtained medications from R1’s locked cabinet and found many expired medications and eyedrops that R1 was self -administering. After R1 was admitted into hospice care on 06/15/21, she was placed under the facility’s managed medication care plan. Hospice care notes show staff followed R1’s prescribed medication program as instructed by the hospice care team. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not ensure that resident is taking medications as prescribed is unsubstantiated.

Allegation: Facility staff did not treat resident with dignity
Investigation Finding: Unsubstantiated
During investigation, staff (ADM, S2, S4) stated they treated each resident (R1) with dignity and respect. LPA reviewed progress notes dated 06/24/21 – 07/15/21 which showed R1’s ongoing care refusal. On 06/25/21 at 10:45 hours, R1 refused care from staff and hospice aide due to her difficult behaviors/attitude during care. Another hospice aide came in and R1 gave no issues to aid after giving issues to the last hospice aid who elected not to return. On 07/01/21 at 17:16 hours, R1 ordered soup for dinner but refused to go down for dinner. When dinner was brought up, R1 refused it because she didn’t want to be charged for room service. Progress summary report dated 07/15/21 show R1 displayed stubbornness and irrational anger towards staff/hospice aide and refusal to eat. Staff stated they continued to provide R1 with care and supervision despite these challenges. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not treat resident with dignity is unsubstantiated.

Exit Interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8