019200726-11-3-2021-15-AS-HHUL-CEXVYD-20220531165059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200726
Report Date: 11/03/2021
Date Signed: 11/03/2021 04:03:51 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
09/09/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210909122733

FACILITY NAME:	SUNRISE CARE HOME II		FACILITY NUMBER:	019200726
ADMINISTRATOR:	TAYAG, NANCY R		FACILITY TYPE:	740
ADDRESS:	1435 VIA LUCAS		TELEPHONE:	(510) 398-8677
CITY:	SAN LORENZO	STATE: CA	ZIP CODE:	94580
CAPACITY:	6	CENSUS: 5	DATE:	11/03/2021
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Nancy Tayag, Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Personal RIghts - Resident sustained multiple pressure injuries while in care

INVESTIGATION FINDINGS:

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On 11/3/2021 at 3:50 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to the deliver finding for the above allegation. LPA met with Administrator, Nancy Tayag and explained the purpose of the visit.

During course of the investigation, the Department conducted interviews with facility residents, staff, witnesses, and complainant. Documents including but not limited to: resident’s (R1) admission agreement, physician’s report, care plan, staff notes, photos of resident, and discharged notes.

REPORT CONTINUES ON 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210909122733

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 CARE HOME II	FACILITY NUMBER: 019200726
	VISIT DATE: 11/03/2021

NARRATIVE

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The Department investigated resident sustained multiple pressure injuries while in care. Based on record review of discharged notes, R1 was admitted to the hospital for “loss of appetite” on September 4, 2021. However, upon admission, it was noted R1 sustained multiple wounds in the following areas: heels, buttocks, lower legs, and hips. On 9/30/2021, R1 was admitted to skilled nursing facility on hospice for wound care.

Staff notes indicated R1 was seen by a doctor on August 11, 2021 for the wounds on R1’s heels. R1 was referred to a podiatrist and an appointment was scheduled for September 1, 2021. However, it was cancelled due to R1 “not feeling well”. Based on interview and record review, R1 was not seen by a doctor for R1’s other wounds. Therefore, there was no doctor’s order for wound care instructions.

Based on the information obtained, interviews and record reviews that the Department obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

A $500 civil penalty is assessed for violation that resulted in a serious injury. Additional civil penalties and/or Administrative Action may occur.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210909122733

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 CARE HOME II	FACILITY NUMBER: 019200726
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/25/2022 Section Cited HSC 1569.269(a)(10)	1 2 3 4 5 6 7	*THIS IS AN AMENDED REPORT FROM VISIT ON 11/3/2021* ENUMERATED RIGHTS; SEVERABILITY (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.	1 2 3 4 5 6 7	Administrator will review regulation and submit self-certification letter to CCL by POC date. A formal meeting will be scheduled at a later time.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and record review, Licensee did not comply with the regulation cited above. R1 sustained multiple wounds while in care which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	$500 Civil Penalty is being assessed.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC9099 (FAS) - (06/04)

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