019200755-4-26-2023-15-AS-HHUL-CRVQE2-20230516120538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 04/26/2023
Date Signed: 04/26/2023 04:57:07 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
03/11/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220311123349

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:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Dillon Cagulada, Administrator and Steve Lackner, Regional nurse		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not respond to call buttons timely

INVESTIGATION FINDINGS:

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On 4/26/2023 at 10:05 AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. LPA met with Administrator Dillon Cagulada, LPA explained the purpose of the visit.

During the investigation, LPA reviewed documents such as but not limited to, incident reports, medication administration records (MAR), residents care plan, physician’s report and facility’s narrative LPA could not interview R1 since she no longer lives at the facility. LPA conducted interview with facility residents and staff.

Continued to LIC9099C…

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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 5

Control Number 15-AS-20220311123349

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: 04/26/2023

NARRATIVE

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Staff do not respond to call buttons timely

During the course of investigation, based on staff interview the facility’s response time to call lights is between 5-10 minutes, if there are multiple calls during the same time, the staff will communicate with each other to check each resident. However, records review revealed that between March 01, 2022- March 8, 2022, there were 50 calls that staff responded for more than 30 minutes.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) 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 to Steve Lackner, Regional nurse.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20220311123349

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/08/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Regional nurse agreed that staff training will be conducted about the facility’s protocol on pendant call response. A proof of training needs to be submitted to CCL by POC date,
	8 9 10 11 12 13 14	Based on records reviewed, facility staff failed to respond to pendants in timely manner, based on records review, there were 50 pendant calls with 25minutes- 30minutes response time, which poses a potential risk to the health and safety of resident under care.	8 9 10 11 12 13 14
	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: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
03/11/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220311123349

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:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Dillon Cagulada, Administrator and Steve Lackner, Regional nurse		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Residents are not changed timely
Residents meals are late
Insufficient staff to meet residents needs

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20220311123349

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: 04/26/2023

NARRATIVE

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Residents are not changed timely

During the course of investigation, interview with staff revealed that residents who needs incontinence care is checked 3-4 times a day. Interviews with staff indicated that residents are checked at least 3-4 times throughout the day for incontinence care/toileting needs. However, when residents have a bowel movement or an accident, staff will change and clean residents right away. LPA conducted interview with residents in care, based on interview, residents stated that staff are checking on them couple of times a day and checks if they need assistance on their incontinence needs. Residents that were interviewed stated they are happy with the service that the staff provides for them.

Residents’ meals are late

During the course of investigation, LPA conducted interview with staff and residents. Based on interview, residents denied staff delivering meals late. Residents and staff stated that meals are delivered during these times; breakfast 7:30AM- 8:00AM, lunch 11:00 AM-11:30AM and dinner 4:30 PM- 5:00PM.

Insufficient staff to meet residents needs

LPA reviewed staff schedule for the facility, facility has Med Tech, support staff and other agency staffing available on schedule. Facility had sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPA conducted interview with residents and residents reported that they are happy living at the facility and had no issues around staff availability to meet their needs. Residents that were interviewed reported that facility staff attend to their needs.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided to Steve Lackner, Regional nurse.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5