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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 06/05/2020
Date Signed: 06/05/2020 11:17:25 AM



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
03/10/2020 and conducted by Evaluator Rolanda Pitcher
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200310151601
FACILITY NAME:SUNRISE ASSISTED LIVING OF OAKLAND HILLSFACILITY NUMBER:
019200755
ADMINISTRATOR:NEVAREZ, KARINAFACILITY TYPE:
740
ADDRESS:11889 SKYLINE BLVDTELEPHONE:
(510) 531-7190
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:100CENSUS: 86DATE:
06/05/2020
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Karina NevarezTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to prevent a resident from harming other residents while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this date, 6/5/20 at 11:00 am, Licensing Program Analyst, (LPA) Rolanda Pitcher conducted a Tele-Visit to deliver complaint findings. LPA spoke to Executive Director, Karina Nevarez for this purpose. On 3/13/20, LPA Pitcher conducted the Initial 10-Day visit and met with Karina Nevarez for this purpose. During the course of this investigation LPA conducted interviews with S1, S2 and provided requested records pertaining to R1.

LPA learned R1 did in fact walk into another resident room expectantly, however, no residents were harmed. Based on LPA's investigation, which included observation. interviews with staff, resident (R1) records and correspondence via email and telephone contact. Furthermore, reporting party denies R1 physically caused harm to the other residing residents.

Report continued on LIC 9099C
Unfounded
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2020
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 2
Control Number 15-AS-20200310151601
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 ASSISTED LIVING OF OAKLAND HILLS
FACILITY NUMBER: 019200755
VISIT DATE: 06/05/2020
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
26
27
28
29
30
31
32
This agency has investigated the complaint allegations listed above. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.



Tele- Visit completed with Karina Nevarez

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2