<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001968
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:42:19 PM


Document Has Been Signed on 03/16/2022 01:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SUNRISE OF ROCKLINFACILITY NUMBER:
315001968
ADMINISTRATOR:MORADHASEL, ROUZBEHFACILITY TYPE:
740
ADDRESS:6100 SIERRA COLLEGE BLVDTELEPHONE:
(916) 632-3003
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:82CENSUS: 56DATE:
03/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Executive Director- Caroline FrangiehTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Talwinder Bains and Michael Hood arrived at the facility and met with Executive Director- Caroline Frangieh, to follow-up on an Incident Report sent by the facility on 3-11-22 regarding resident (R1). Facility currently does not have any COVID-19 positive cases. LPAs wore N-95 mask and was screened by facility upon entry. Facility staff wore masks in the facility .

During today's visit, LPAs interviewed staff members and reviewed documentation in R1's file pertinent to the incident. LPAs requested that facility obtained a death certificate for R1. LPAs will follow-up with facility regarding incident once facility obtains a death certificate for R1.


At this time, further investigation is needed regarding information above.

Exit interview was conducted with Caroline and a copy of this report was provided to the facility.
There were no deficiencies cited during today's visit.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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 1