079200294-5-23-2022-15-AS-LFRO-CEPREP-20220523125754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200294
Report Date: 05/23/2022
Date Signed: 05/23/2022 12:58:07 PM

Document Has Been Signed on 05/23/2022 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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 DANVILLE		FACILITY NUMBER:	079200294
ADMINISTRATOR:	KIRSTEN KORFHAGE		FACILITY TYPE:	740
ADDRESS:	1027 DIABLO RD		TELEPHONE:	(925) 831-1740
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	89	CENSUS: 72	DATE:	05/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Kirsten Korfhage, Executive Director		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/23/2022 starting at 10:05 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Fici arrived unannounced to conduct Infection Control Inspection. LPAs met with Executive Director Kirsten Korfhage and explained the purpose of the visit. During the Infection Control Inspection, LPAs toured facility with Executive Director including but not limited to front entrance, screening station, hand washing stations, random residents apartments, common areas, multiple activity rooms, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. At 11:10 AM, LPAs reviewed 6 staff records and 4 of 6 staff have health screening and TB test records on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff digitally. THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT At 11:35 AM during record review, LPAs observed S1 and S2 does not have health screening and TB test on file REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 DANVILLE	FACILITY NUMBER: 079200294
	VISIT DATE: 05/23/2022

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 6/3/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2022 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 DANVILLE	FACILITY NUMBER: 079200294
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPAs observed S1 and S2 does not have health screening and TB test on file which poses a potential healt and safety risk to persons in care.
	POC Due Date: 06/08/2022
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to obtain a health screening and TB test for S1 and S2 and submit a copy of LIC 503 with TB test result to CCLD.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC809 (FAS) - (06/04)

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