216803735-3-3-2021-21-AS-CMAZ-BLPVGF-20200211152527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803735
Report Date: 12/17/2019
Date Signed: 03/03/2021 03:42:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2019 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20190625094348

FACILITY NAME:	SUNRISE OF SAN RAFAEL		FACILITY NUMBER:	216803735
ADMINISTRATOR:	APONLINARIO, ABBIE		FACILITY TYPE:	740
ADDRESS:	111 MERRYDALE ROAD		TELEPHONE:	(415) 472-6530
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	70; 70; 70	CENSUS:	DATE:	12/17/2019
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Nathan Nayton - Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Severe neglect resulting in resident sustaining multiple face fractures.

INVESTIGATION FINDINGS:

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*** Amended*** After review of appeal received , findings amended to unsubstatiated. The Department is citing facility under a Case Management.
The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Adam Syncheff-Bus. Off. Coordinator
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”.
Continue LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20190625094348

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/17/2019

NARRATIVE

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*** Amended*** After review of appeal received , findings amended to unsubstantiated. The Department is citing facility under a Case Management.

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. However, as per appeal, there are no facts supporting the conclusion that the resident's accidental fall was the result of any neglect or negligence on the part of facility staff. (see confidential name list, LIC 809-D)

According with complaint allegation " Severe neglect resulting in resident sustaining multiple face fractures.” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20190625094348

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/17/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 12/31/2019 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Amended Citation dismissed. 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 &	1 2 3 4 5 6 7	Facility agrees to submit a plan and procedure regarding residents needing medical attention due to a fall/injury and how medical attention will be provided.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14	Submit plan and procedure to CCL by POC 12/31/2019.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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