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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803735
Report Date: 03/03/2021
Date Signed: 03/03/2021 03:39:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SUNRISE OF SAN RAFAELFACILITY NUMBER:
216803735
ADMINISTRATOR:LAYTON, NATHAN W.FACILITY TYPE:
740
ADDRESS:111 MERRYDALE RDTELEPHONE:
(415) 472-6530
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:70CENSUS: DATE:
03/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nathan W. Layton - Executive DirectorTIME COMPLETED:
12:15 PM
NARRATIVE
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License Program Analyst (LPA) Fernandes-Goes conducted a case management for this facility due to an amended complaint # 21-AS-20190625094348 that was investigated and closed on December 17, 2019. Corporation filled an appeal by Tom Berry - Regional Director of Operations and complaint has changed from Substantiated to Unsubstantiated. However, as per appeal letter response dated May 26, 2020 from Ley Arquisola Program Administrator for Adult & Senior Care Program citation stays under a case management changed from Type A to B. This visit was conducted virtually due to COVID-19. LPA met with Executive Director Nathan W. Layton.

The Department conducted a complaint investigation for complaint # 21-AS-20190625094348 which was closed on December 17, 2019. The following was observed during this complaint investigation.
On 6/26/2019 LPA D’Asto toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During interviews Executive Director Abbie Aponlinario and documentation review on 6/26/2019, LPA learned that resident R1 had an incident of fall at 1:20 PM and wasn’t sent to ER until 7:45 PM. As per discharge papers for resident R1, resident have “broken (fractured) one or more bones in ‘R1’s’ face.” Discharged papers for resident R1 dated - Adm: 6/18/2019, D/C: 6/19/2019”.

In the case of resident R1, facility did not seek timely medical attention as required by Title 22 Regulations based on documentation and as stated by facility staff statement & documentation provided on 6/26/2019.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SUNRISE OF SAN RAFAEL
FACILITY NUMBER: 216803735
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2021
Section Cited

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87465(g)Incidental Medical and Dental Care Services. 9-1-1 shall be telephoned immediately if an injury or other circumstance ... This requirement is not met as evidenced by: **Based on LPAs documentation review &
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interviews facility didn't comply w/ regulation above on 1 of 1 resident;R1 had a fall on 6/18/19 at 1:20 PM & 9-1-1 wasn't contacted until 7:45 PM which poses an immediately health, safety,&personal rights risk to residents in care.
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Facility has already cleared this citation due to being related to a complaint that was closed on 12/17/2019.

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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: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2021
LIC809 (FAS) - (06/04)
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