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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 10/20/2020
Date Signed: 10/20/2020 10:35:03 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
09/25/2020 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200925114253
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: 85DATE:
10/20/2020
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Karina NevarezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility not notifying responsible party of incidents, staff not assisting resident with ADLs, temperature in resident's room is not within regulation range.
INVESTIGATION FINDINGS:
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On 10/20/2020 LPA Allison O'Hollaren and AGPA Jeremy Fong conducted an unannounced continuing complaint visit, meeting with S1. Due to State's Current Shelter in Place Order this visit was conducted by telephone.

During the investigation it was found that the facility made several attempts to contact the subject resident's responsible party following incidents; identified neutral witnesses who stated that staff are assisting residents with ADLs and that the room temperature has consistently been within a comfortable range.

The Department has investigated these allegations and based upon LPA's observations, interviews conducted, and records reviewed, these allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although
Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
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-20200925114253
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: 10/20/2020
NARRATIVE
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the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations have occurred.

Exit interview conducted with S1 and a copy of this report was provided via email and general mail.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2