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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 12/22/2023
Date Signed: 12/22/2023 12:00:28 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
06/13/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230613081142
FACILITY NAME:SUNRISE ASSISTED LIVING OF OAKLAND HILLSFACILITY NUMBER:
019200755
ADMINISTRATOR:CAGULADA, DILLON RFACILITY TYPE:
740
ADDRESS:11889 SKYLINE BLVDTELEPHONE:
(510) 531-7190
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:100CENSUS: DATE:
12/22/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Deborah SavoieTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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9
Staff left residents in soiled diapers for extended amount of time.
Staff are not meeting residents hygienic care needs
Licensee does not ensure facility toilets/showers are in good repair.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver findings on the above allegations. LPA met with Executive Director Deborah Savoie and explained the purpose of visit.

During the course of investigation, LPA interviewed two Directors and five caregivers. LPA interviewed caregivers who are currently employed under Ivy Park and have worked for the previous management, Sunrise Assisted Living. Ivy Park took over from Sunrise Assisted Living on 7/1/2023.

Based on interviews conducted, staff needed to provide care to 10-13 residents due to short staffing. S5 states there was a time when S5 was the only caregiver who showed up in the assisted living. S5 states there were approximately 60 plus residents that needed care. S5 states there were no managers available to assist with the staffing issues despite calls made.

continuation on Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
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-20230613081142
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: 12/22/2023
NARRATIVE
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continuation from Lic 9099

Staff interviewed state that due to the lack of staffing, there is a delay in providing care for the residents. The facility did not obtain services from any agency for additional staffing.

On 10/24/2023, LPA interviewed the Maintenance Director who confirmed with LPA that when he took over the position from the previous director, he needed to replace 5 toilet seats and install 2 shower heads, among other things.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22 are cited on the attached LIC 9099D.

Exit interview was conducted with Executive Director and Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
06/13/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230613081142

FACILITY NAME:SUNRISE ASSISTED LIVING OF OAKLAND HILLSFACILITY NUMBER:
019200755
ADMINISTRATOR:CAGULADA, DILLON RFACILITY TYPE:
740
ADDRESS:11889 SKYLINE BLVDTELEPHONE:
(510) 531-7190
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:100CENSUS: DATE:
12/22/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Deborah SavoieTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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5
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9
Resident sustained fracture in the femur while in care.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver findings on the above allegation. LPA met with Deborah Savoie and explained the purpose of the visit.

During the course of investigation, the Department conducted interviews and record reviews.
Facility staff suspected Staff 13 (S13) of injuring Resident 1 (R1) as S13 was the last staff person to be seen with R1 before R1 went to the hospital. Although R1 is bedbound and unable to walk, staff and R1’s son stated R1 can sit up without assistance and can move around using upper body strength.

When S13 returned to work on a Tuesday (exact date unknown), S13 noticed R1s leg was swollen and immediately reported it to the med tech on duty. On 5/9/2023, R1 was transported to the Alta Bates Summit Medical Center Emergency Department (ED). X-ray results showed a fracture along the right proximal tibia from R1’s prior total knee replacement. R1 was not aware that R1 sustained a fracture and did not have anything negative to say about S13. R1’s son had no complaints about S13 and said S13 takes good care of R1. continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230613081142
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: 12/22/2023
NARRATIVE
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continuation from Lic 9099

S13 denied injuring R1 and did not know how R1 sustained a fracture. There were no incident reports or shift notes that noted of any falls that R1 sustained during the time period. Based on interviews conducted and records reviewed, the above allegation is unsubstantiated

Although the allegation may have happened or is valid, there is not a preponderance of
evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230613081142
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: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) 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, residents in privately operated residential care facilities…
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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The administrator will submit to CCL plan on how to ensure there is sufficient qualified staff to meet the needs of the residents by POC date.
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Based on interviews conducted, Licensee failed to meet and deliver services to the residents due to the insufficient number of staff which poses a potential risk to health and safety of residents under care.

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Type B
01/05/2024
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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By POC date, Administrator will send to CCL Maintenance and Operation Plan to ensure the facility is in good repair at all times.
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Based on interviews conducted, the Licensee failed to maintain facility in good repair in having wobbly toilet seats/missing shower heads which poses
a potential risk to the health and safety of residents.

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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5