<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601336
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:12:58 PM


Document Has Been Signed on 05/22/2024 04:12 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 PRIVATE CAREFACILITY NUMBER:
015601336
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:3234 EAST AVENUETELEPHONE:
(925) 449-0426
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 0DATE:
05/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Elizabeth Nagy, AdministratorTIME COMPLETED:
04:25 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 5/22/2024 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection. LPA met with Administrator, Elizabeth Nagy.

During the course of investigation for complaint (#15-AS-20240130092450), the following deficiencies were observed.

Licensee did not notify residents and/or family members in writing regarding the facility's renovations and needing the residents to relocate.

Also, facility did not notify CCLD regarding the facility's renovations and needing the residents to relocate.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/22/2024 04:12 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 PRIVATE CARE
FACILITY NUMBER: 015601336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2024
Section Cited
CCR
87468(a)

1
2
3
4
5
6
7
Personal Rights. Residents in residential care facilities for the elderly shall have personal rights which include...those listed in Sections 87468.1...and 87468.2... This requirement is not met as evidence by:
1
2
3
4
5
6
7
Facility has agreed to review the regulations pertaining to personal rights and submit written statement of understanding to CCLD by POC date.
8
9
10
11
12
13
14
Based on investigation, licensee did not comply with the section cited above by not providing written notice regarding facility renovation which poses a potential personal rights violation to the persons in care.
8
9
10
11
12
13
14
Type B
06/10/2024
Section Cited
CCR87211(a)(1)

1
2
3
4
5
6
7
Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days... specified in (A) through (D) below... This requirement is not met as evidence by:
1
2
3
4
5
6
7
Facility has agreed to submit a written statement detailing facility renovations and submit a copy to CCLD by POC date.
8
9
10
11
12
13
14
Based on investigation, licensee did not comply with the section cited above by not notifying CCLD regarding facility renovations which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2