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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 07/20/2021
Date Signed: 07/20/2021 02:02:37 PM



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
07/20/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200720092014
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: 87DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Karina Nevarez, Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Lack of supervision resulting in resident wandering away from facility.
INVESTIGATION FINDINGS:
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On 7/20/2021 at 11:30 AM, Licensing Program Analysts (LPAs), L. Hall and G. Luk arrived unannounced to investigate and deliver complaint findings of the above allegation. LPAs met with Executive Director, Karina Nevarez, and explained the reason for the visit.

During the course of investigation, LPAs interviewed staff, reviewed staff schedule, residents' roster, and resident's file including physician's reports, care plans, and incident report. According to the staff schedule, there was a staff on duty at night shift. Interview with staff revealed that staff was present during the incident on the evening of 07/19/2020. However, physician's report stated that R1 was not able to leave facility on his own.

Contined on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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 3
Control Number 15-AS-20200720092014
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: 07/20/2021
NARRATIVE
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Continued from LIC9099.

Based on investigation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC 9099D.

Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20200720092014
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: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 (a )Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe... accommodations... This requirement was not met as evidence by:
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Executive Director have spoken with responsible party, 1:1 was provided for R1, resident moved into memory care 7/21/2020. Deficiency cleared.
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Based on record reviews licensee did not comply with the section cited above by allowing resident to leave the facility unassissted, which poses an immediate health and safety risk to persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3