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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202358
Report Date: 11/07/2022
Date Signed: 11/09/2022 08:46:58 AM


Document Has Been Signed on 11/09/2022 08:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



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: 75DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nina Spencer (RN)- Resident Care DirectorTIME COMPLETED:
02:36 PM
NARRATIVE
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On 11/7/2022 at 11:30 a.m. Licensing Program Analyst (LPA) B. Miranda conducted an unannounced Case Management -Incident visit. LPA was Covid screened at the lobby area. LPA was met by Resident Care Director (RCD) Nina Spencer.

The facility consists of assisted living, memory care, and transitional living. A short tour was conducted, and no deficiencies were noticed at this time. Two fire extinguishers on the second floor are current and serviced up to date.

Facility had a resident who tested positive for a serious infection. This infection was considered prohibited and an exception was not requested.

In accordance with Title 22 two type A citations were issued. Prohibited Health Conditions 87615 (a)(4) and Exceptions for Health Conditions 87616 (a).

Refer to LIC 809D if necessary


Exit interview conducted
Report provided
Appeal rights provided
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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 11/09/2022 08:46 AM - 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: SUNRISE ASSISTED LIVING OF MONTEREY
FACILITY NUMBER: 275202358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited

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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (4) Staphylococcus aureus ("staph") infection or other serious infection.
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This requirement is not met as evidenced by: Based on interviews and record reviews LPA observed the facility had a resident with a serious infection in the facility which is prohibited without an exception. This poses an immediate health and safety and or
personal rights risk to residents in care.
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Type A
11/08/2022
Section Cited

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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This requirement is not met as evidenced by:
Based on interviews and record reviews LPA observed the facility failed to request an exception for R1 who had a serious infection. This poses an immediate health and safety and or personal rights risk to residents in care.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2