019200755-8-23-2022-15-AS-HHUL-CMJQ3M-20221228104855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 08/23/2022
Date Signed: 08/23/2022 03:47:18 PM

Unsubstantiated

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
07/13/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20210713153428

FACILITY NAME:	SUNRISE ASSISTED LIVING OF OAKLAND HILLS		FACILITY NUMBER:	019200755
ADMINISTRATOR:	NEVAREZ, KARINA		FACILITY TYPE:	740
ADDRESS:	11889 SKYLINE BLVD		TELEPHONE:	(510) 531-7190
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94619
CAPACITY:	100	CENSUS: 73	DATE:	08/23/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Dillon Cagulada, Executive Director		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Personal Rights - Neglect/lack of care and supervision resulted in questionable death of the resident
Staff were not providing adequate food service to resident
Staff are mismanaging residents medication
Electricity in residents room is in disrepair

INVESTIGATION FINDINGS:

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On 8/23/2022 at 11:00 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to deliver findings for the above allegations. LPAs met with Executive Director, Dillon Cagulada and explained the purpose of the visit.

During course of the investigation, the Department conducted interviews with facility staff, witnesses and complainant. Documents including but not limited to: R1’s admission, physician’s report, care plan, medication log, incident report, discharge notes, maintenance log, death certificate, hospice notes and medication order.

REPORT CONTINUES ON 9099C

Unsubstantiated

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: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

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-20210713153428

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: 08/23/2022

NARRATIVE

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The Department investigated Neglect/lack of care and supervision resulted in questionable death of the resident. Based on information obtained from complainant, death certificate indicated resident’s cause of death was due to malnourishment. However, the Department received records indicating resident was receiving hospice care under Suncrest Home Health with a diagnosis of Alzheimer’s Dementia. During an interview, W1 stated there was nothing concerning about resident’s death and that it is common for patients’ appetite to change with Alzheimer’s Dementia. Resident’s service plan on 10/13/2020 indicated resident is a nutritional risk, therefore the goal of the facility was to meet and receive resident’s diet as ordered. S1 and S2 said when resident would refuse to eat, staff would encourage resident and notify hospice.

It was alleged staff were not providing adequate food service to resident. The Department's interview with S2 revealed that resident was receiving 3 meals and 2 snacks a day. On 8/23/2022, LPAs interviewed 5 residents and 5 of 5 residents stated they receive their meals and have no issues with the food service.

It was alleged staff are mismanaging residents medication. Based on information obtained by complainant, resident was given a pill in apple sauce instead of morphine. However, LPAs reviewed resident's doctor's order and observed there is an order for Tylenol to be taken orally every 6 to 8 hours as needed for pain.

It was alleged electricity in residents room is in disrepair. On 8/23/2022, LPAs reviewed maintenance log from August 2020 to November 2020 and did not observe any requests for electrical issues for resident's room.

This agency has investigated the complaint. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Executive Director 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: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC9099 (FAS) - (06/04)

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