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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 09/11/2024
Date Signed: 09/11/2024 10:37:54 AM

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
06/05/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230605134647
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: 70DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yolanda Harrell, Executive Director (ED)TIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Staff do not provide medical information of a resident to emergency professionals
INVESTIGATION FINDINGS:
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On 9/11/2024 at 10AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver complaint findings for the allegations above. LPA met with Yolanda Harrell, Executive Director (ED) LPA explained the purpose of the visit.

Allegation: Staff do not provide medical information of a resident to emergency professionals

During the course of investigation, based on staff interview the facility did not provide medical information of a resident to emergency professionals. 8 out of 8 staff indicated that they did not have access to the computer and wasn’t allowed to access the resident information to provide to EMT. 8 out of 8 staff stated that during the night shift to near morning staff do not have access to resident information.

Report Continue on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
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-20230605134647
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: 09/11/2024
NARRATIVE
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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 Yolanda Harrell, Executive Director (ED)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230605134647
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: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
87508(a)
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87508
Register of Residents

(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information
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Executive director (ED) agrees to send in a self-certified letter to CCLD by POC date that ED review the regulation and ensure that all residents medical emergency information is updates and staff have access to prepare and provide to emergency professional when needs.
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Based on interviews conducted, Licensee failed to meet and provide resident medical information to the emergency professional due not being able to access the computer to obtain resident medical information which poses a potential risk to health and safety of residents under 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3