079200294-1-11-2024-15-AS-AGOZ-CZE2DQ-20240111161843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200294
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:18:53 PM

Document Has Been Signed on 01/11/2024 04:18 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
OAKLAND ASC, 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: 80	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Executive Director, Kirsten Korfhage		TIME COMPLETED:	04:30 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	Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a 1-Year Annual Required inspection on this date starting at 12:00pm. LPA met with Executive Director, Kirsten Korfhage and explained the reason of the visit. The facility's fire clearance was approved for all may be non-ambulatory which 10 may be bedridden. At 3:10pm, LPA toured facility with Executive Director, including but not limited to apartments, bathrooms, kitchen, dining area, multiple activity rooms and courtyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the random residents’ bathroom were maintained at 115.2 and 110.3 degrees F. Residents’ bathrooms are equipped with grab bars and non-skid mats/non-skid shower pans. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication carts were inaccessible. Refrigerator temperature was maintained at 36 degrees F and freezer temperature is maintained at -13 degrees F. Smoke detectors, carbon monoxide and sprinklers were observed throughout the facility. Fire extinguisher was last serviced on 10/14/2023 . Emergency Disaster Plan was last posted on 10/20/2023. First aid kit was observed to be complete. Fire drill was last conducted on 12/27/2023. At 12:40pm, LPA reviewed 5 residents records. At 3:25pm, LPA reviewed 5 staff records and 5 of 5 staff are fingerprint cleared. REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SUNRISE ASSISTED LIVING OF DANVILLE	FACILITY NUMBER: 079200294
	VISIT DATE: 01/11/2024

NARRATIVE

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The Following Deficiencies were observed:

At 1:42PM during facility tour LPA observed unlocked full sharps disposal container in R5's room in closet on the floor. ED had med-tech dispose of bin. Deficiency Cleared.
Between 1:45PM and 2:03PM during facility tour LPA observed Virex cleaner, scissors, and prescription powder in R1's apartment . LPA also observed scissors and whiskey in R3's apartment. ED removed all items from residents apartments clearing the deficiency.
At 3:30PM during staff file review LPA observed that S4 does not have a health screen or TB test on file.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 2/01/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (9 pages)
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 deficiency by POC date may result in Civil Penalties.

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

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/11/2024 04:18 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
OAKLAND ASC, 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: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in R1, R3, and R5 having dangerous items which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Executive Director removed all items during visit and will do a sweep of residents rooms to ensure there are no other dangerous items. Deficiency Cleared

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/11/2024 04:18 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
OAKLAND ASC, 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: 01/11/2024

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 in S4 not having a health screening or TB test on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/01/2024
	Plan of Correction
1 2 3 4	By POC date Executive Director agrees to ensure all staff have the required health sceen and self certify 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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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