019200755-6-29-2021-15-AS-YFLS-C7GV9K-20211004161427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200755
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:52:36 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
04/16/2020 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200416134431

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: 86	DATE:	06/29/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Karina Nevarez, Executive Director		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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-Facility failed to provide proper care & supervision to resident
-Facility failed to equip resident accommodations with appropriate bedding
-Facility failed to store medications inaccessible to resident
-Facility failed to meet reporting requirements
-Facility neglected to meet resident's level of care needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Executive Director to deliver findings on the above allegations. Due to the present shelter in place order by the Governor, this inspection was conducted via phone conference.

It was alleged that on 3/16/20, R1 was left alone in the room on the floor with only a thin blanket and no clothing while awaiting emergency services due to necessary medical intervention. It was also alleged that there were medication bottles unlocked and open in the room. During the investigation, LPA conducted interviews, made observations, and obtained documentation and information related to the allegations, including but not limiting to R1's Physician's Report, Hospice Care Plan, Incident Report, Care Plans, Death Report, Controlled Drug Records, Centrally Stored Medication Logs, and Medication Administration Records, and Physician's Orders.

[SEE LIC-9099C for continued report]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200416134431

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: 06/29/2021

NARRATIVE

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R1 had been receiving Hospice care since 3/14/20. It was reported to CCL that at the time of the incident, a Hospice Nurse was with R1 and had instructed staff to call 911 due to R1's spinal pain and possible head injury. However, unbeknownst to facility staff, the Hospice Nurse left R1 alone. Emergency personnel arrived just as the Hospice Nurse was leaving the building. It was also reported that there were empty viles of Morphine left behind by the Hospice Nurse.

R1 was taken to the hospital but returned the same day. R1 passed away at the facility due to Respiratory failure and overall decline in health on 3/20/20.

Based on the information gathered, not a substantial amount of evidence could be obtained to support that facility staff failed to provide R1 proper care and supervision or that staff neglected to meet R1's needs when it was the Hospice Nurse who was with R1 at the time of the incident. Further, a substantial amount of evidence could not be found to support that R1 did not have proper bedding at the time of the incident or that the facility did or did not meet mandated reporting requirements.

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

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

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