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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200294
Report Date: 10/19/2023
Date Signed: 10/19/2023 10:29:59 AM

Document Has Been Signed on 10/19/2023 10:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNRISE ASSISTED LIVING OF DANVILLEFACILITY NUMBER:
079200294
ADMINISTRATOR:KIRSTEN KORFHAGEFACILITY TYPE:
740
ADDRESS:1027 DIABLO RDTELEPHONE:
(925) 831-1740
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 89CENSUS: 78DATE:
10/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kirsten Korfhage, Executive DirectorTIME COMPLETED:
10:45 AM
NARRATIVE
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On 10/19/2023 at 9:20am, Licensing Program Analysts (LPAs) A Gomez and L. Francisco arrived unannounced to conduct Case Management regarding an AWOL incident report received for Resident 1(R1) on 9/27/2023 visit. LPAs met with Kirsten Korfhage, Executive Director (ED), and explained the purpose of the visit.

Incident report was for an AWOL for Resident (R1). Executive Director (Ed) self- reported that At about 2:45pm on 9/20/2023 R1 was not in their apartment. Community staff looked for R1 but they were not found. During community sweep it was identified that R1 had signed themself out of the community. ED drove to R1’s home and found that R1 had been picked up by R1’s neighbor who brought R1 back to the community.



During record review, LPAs observed that physician's report dated 9/14/2023 stated that R1 cannot leave the facility unassisted.

LPAs collected the following documents during visit: R1's Physicians Report

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to submit proof of corrections (POCs) by plan or correction due dates and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Executive Director.

Exit interview conducted. Appeal Rights and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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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Document Has Been Signed on 10/19/2023 10:29 AM - It Cannot Be Edited


Created By: Alona Gomez On 10/19/2023 at 10:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited

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87468.2 ADDITIONAL PERSONAL RIGHTS OF RESIDENTS....
(a) In addition to the rights listed in Section 87468.1, ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(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.
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This requirement is not met as evidence by: based on record review, licensee did not comply with the section cited above. R1’s physician report states that R1 is not able to leave the facility unassisted which poses a potential health and safety risk to the residents 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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