275202358-11-22-2022-24-AS-MHON-CLTU25-20221205141121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202358
Report Date: 11/22/2022
Date Signed: 11/22/2022 12:19:36 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2022 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20220802093326

FACILITY NAME:	SUNRISE ASSISTED LIVING OF MONTEREY		FACILITY NUMBER:	275202358
ADMINISTRATOR:	PAUL L. HARRISON		FACILITY TYPE:	740
ADDRESS:	1110 CASS ST		TELEPHONE:	(831) 643-2400
CITY:	MONTEREY	STATE: CA	ZIP CODE:	93940
CAPACITY:	112	CENSUS: 77	DATE:	11/22/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Paul Harrison, Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff falsified residents' documentation

INVESTIGATION FINDINGS:

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On 11/22/22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegation. LPA was greeted by concierge, stated the purpose of the visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry. LPA met with Executive Director (ED) to discuss findings.

During the investigation, LPA conducted interviews and records review. LPA observed Preplacement Appraisals (LIC 603a) and Physician's Reports (LIC 602a) for four new residents in care. Records review show LIC603a and LIC602a to be consistent in comparison regarding the care needs of the residents.

(Continued on 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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 24-AS-20220802093326

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUNRISE ASSISTED LIVING OF MONTEREY	FACILITY NUMBER: 275202358
	VISIT DATE: 11/22/2022

NARRATIVE

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LPA observed a fax request from the facility to Resident R1's physician requesting a change on R1's LIC 602. Change request was based on an incident reported by R1 and R1's responsible party. Fax request was observed to have an electronic date and time stamp by the physician and facility.

We have found that the complaint was unfounded, meaning that the allegation is false, could not have happened and or is without reasonable basis, therefore, we have dismissed the complaint. Exit interview conducted. A copy of this report was provided to Executive Director.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC9099 (FAS) - (06/04)

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