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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202358
Report Date: 01/12/2022
Date Signed: 01/14/2022 08:53:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:SUNRISE ASSISTED LIVING OF MONTEREYFACILITY NUMBER:
275202358
ADMINISTRATOR:PAUL L. HARRISONFACILITY TYPE:
740
ADDRESS:1110 CASS STTELEPHONE:
(831) 643-2400
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:112CENSUS: 76DATE:
01/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Paul HarrisonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a follow up Case Management Visit regarding incident report involving resident (R1) elopement from the facility.

On 6/12/2021 at 9:20pm Memory Care Delayed egress door alarm sounded. Staff checked the surrounding area but did see any person or resident outside of the community. Staff did not conduct a head count of the residents in Memory Care. At 10:10pm the Monterey Police Department contacted the facility advising a resident had been found near by. Staff picked up R1 and returned R1 to the facility. R1 was not injured. Responsible Party and Primary Care Provider were notified.
Medical records reviewed noted that R1 is not able to leave the facility unassisted.

R1 was provided a wander guard bracelet for safety in the event of wandering or exiting behaviors.

Staff Training conducted on Elopement and Missing Residents. Training included Missing Resident Checklist, Safe Leaving Program, Action Steps and Reporting Procedures.

An Advisory Note LIC9102 was provided under Regulation 87705 Care of Persons with Dementia.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Paul Harrison Executive Director and a copy provided,
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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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