315001968-3-25-2022-27-AS-APEZ-CD3UCU-20220401152828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315001968
Report Date: 03/25/2022
Date Signed: 03/25/2022 01:15:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2021 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 27-AS-20210225150536

FACILITY NAME:	SUNRISE OF ROCKLIN		FACILITY NUMBER:	315001968
ADMINISTRATOR:	MORADHASEL, ROUZBEH		FACILITY TYPE:	740
ADDRESS:	6100 SIERRA COLLEGE BLVD		TELEPHONE:	(916) 632-3003
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95677
CAPACITY:	82	CENSUS: 56	DATE:	03/25/2022
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Vandhana Devi, Resident Care Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility did not observe changes in resident's physical condition.

Facility did not allow resident's physical therapist into facility.

INVESTIGATION FINDINGS:

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On 3/25/2022, Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains arrived at the facility and met with Resident Care Director (RCD), Vandhana Devi, to conclude a complaint investigation into the allegations listed above. LPAs wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises.

During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility did not observe changes in resident's physical condition

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 8

Control Number 27-AS-20210225150536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUNRISE OF ROCKLIN	FACILITY NUMBER: 315001968
	VISIT DATE: 03/25/2022

NARRATIVE

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Resident's (R1) Weights and Vitals Summary documented by the facility indicates that R1 weighed 174.6 lbs on 1/18/2020 upon admission and weighed 138 lbs on 2/6/2021 around the time R1 moved out of the facility. R1’s Weights and Vitals Summary indicates that facility notated observations of weight change on 3/16/2020 (R1 weighed 167 lbs with 3.0% weight loss), 8/10/2020 (R1 weighed 157 lbs with 10.0% weight loss), 9/8/2020 (R1 weighed 166.4 lbs with 3.0% weight gain), 10/6/2020 (R1 weighed 158.2 lbs with 3.0% weight loss), 11/8/2020 (R1 weighed 163 lbs with 3.0% weight gain), and 1/6/2021 (R1 weighed 144 lbs with 10.0% weight loss). R1’s Weights and Vitals Summary does not document whether facility reported changes in R1’s weight to either R1’s primary care physician or responsible party.

Facility’s Residency Agreement states on page 4 that “If the Resident’s condition changes so that the previously assessed Service Level is no longer appropriate, the Community will reevaluate the Resident’s needs to determine which Service Level is appropriate and notify the Resident/Responsible Party of such reevaluation.” As of today’s date, facility could not provide documentation as to whether R1’s primary care physician or responsible party was notified regarding R1’s change in condition due to weight loss, or whether a Service Level assessment was conducted for R1.

Allegation: Facility did not allow resident's physical therapist into facility.

On 3/25/2020, CCLD was informed that facility was not allowing medical professionals, specifically Physical Therapists (PT), to come provide services for residents. LPA Mai Thao called the facility at 11:10 AM spoke with Executive Director (ED), Scott Bracken. ED stated that the facility is allowing home health for wound care but, other than that, PT is not consider essential and the facility is denying PT access. ED stated that accepting PT inside the facility was against the company’s policy. The department informed the facility that PT is considered essential visitors.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with RCD. A copy of this report and appeal rights were provided. The RCD’s signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 27-AS-20210225150536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUNRISE OF ROCKLIN	FACILITY NUMBER: 315001968
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/08/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident -The licensee shall ensure that residents are regularly observed for changes(...)such as unusual weight gains or losses(...)the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director (ED) will complete a statement of understanding indicating that the facility is aware of the responsibilities to address residents' change in condition and include a copy of the facility's procedures and policies regarding changes in condition. ED will submit statement of understanding and procedures and polices to department by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure that R1's physician and responsible person were notified of changes in weight, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 04/08/2022 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall(...)provide for assistance in obtaining such care(...)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ED will complete a statement of understanding indicating that the facility is aware of what consistutes essential medical care and include a copy of the facility's procedures and policies regarding essential medical. ED will submit statement of understanding and procedures and polices to department by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, the facility did not ensure that R1's PT was able to provide medical services to R1, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2021 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 27-AS-20210225150536

FACILITY NAME:	SUNRISE OF ROCKLIN		FACILITY NUMBER:	315001968
ADMINISTRATOR:	MORADHASEL, ROUZBEH		FACILITY TYPE:	740
ADDRESS:	6100 SIERRA COLLEGE BLVD		TELEPHONE:	(916) 632-3003
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95677
CAPACITY:	82	CENSUS: 56	DATE:	03/25/2022
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Vandhana Devi, RN		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.

Facility did not administer medications as prescribed.

Staff did not assist resident with ADLs.

Facility did not manage resident's incontinence needs.

Facility did not provide food options for resident.

INVESTIGATION FINDINGS:

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On 3/25/2022, Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains arrived at the facility and met with Resident Care Director (RCD), Vandhana Devi, to conclude a complaint investigation into the allegations listed above. LPAs wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises.

During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Resident sustained pressure injuries while in care.

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 27-AS-20210225150536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUNRISE OF ROCKLIN	FACILITY NUMBER: 315001968
	VISIT DATE: 03/25/2022

NARRATIVE

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Resident's (R1) Preplacement Appraisal Information dated 1/10/2020 does not list any pressure injuries observed prior to admission to facility. Facility care notes noted that R1 refused a skin assessment on 1/18/2020 during the time R1 was admitted to the facility.

Per facility care notes, R1 had a hospital visit on 2/26/2020 with no observation of pressure sores. R1 had a hospital visit on 3/4/2020 with complaints of open sores on buttocks area. Doctor observed redness in area but no open wounds.

R1 was admitted to Suncrest Hospice on 12/18/2020 with redness on coccyx area. Hospice notes dated 12/18/2020 indicated that hospice nurse educated both R1 and staff on repositioning for R1. Hospice notes for 12/18/2020 also indicated that R1 was refusing help from staff regarding repositioning.

Hospice identified redness as a stage 2 pressure ulcer during visit on 12/24/2020. Hospice educated both R1 and staff on repositioning for R1. Hospice notes document multiple visits in which R1 refused to cooperate with hospice nurse’s recommendations of repositioning and refused assistance from staff with repositioning. Hospice notes document that when R1 cooperated with repositioning, pressure sores either improved or stopped progressing. When R1 refused to cooperate with hospice’s recommendations, pressure sores worsened.

On 1/19/2021, Suncrest Hospice provided and placed a trapeze in R1’s apartment to assist with repositioning. R1 requested that trapeze be removed from R1’s apartment. Trapeze was removed on 2/1/2021. On 2/1/2021, Suncrest Hospice ordered halo rings to be installed on R1’s bed to help with self-repositioning. R1 requested that halo rings be removed from bed. On 2/2/2021, halo rings were removed from R1’s bed. Hospice notes indicate that R1 refused assistance with repositioning until R1 moved out of the facility.

Allegation: Facility did not administer medications as prescribed.

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 27-AS-20210225150536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUNRISE OF ROCKLIN	FACILITY NUMBER: 315001968
	VISIT DATE: 03/25/2022

NARRATIVE

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Interview with relevant party indicated that R1 was experiencing diarrhea for 2 weeks prior to moving out of the facility but was still receiving PRN medications for constipation. Facility’s MAR for R1 indicated that the only PRN medication administered for constipation (Docusate Sodium) was administered to R1 on 2/3/2021 and 2/8/2021. No other PRN medications assisting with constipation were administered in the month of February.

Interview with Executive Director, Rouzbeh Moradhasel, on 3/3/2021, as well as R1’s charting notes indicate that R1 had six (6) bowel movements on 2/15/2021 and three (3) bowel movements on 2/16/2021. No PRN medications pertaining to constipation were administered to R1 on these dates.

Interview with relevant party indicated that staff were administering PRN pain medications to R1 without asking if R1 needed the PRNs. Hospice care notes provided by Suncrest Hospice indicated that, on multiple dates, R1 requested PRN pain medications after already being on heavy pain medication. Hospice care notes dated 1/6/2021 indicated that hospice nurse educated R1 on excessive opiate use. Medical records provided by Kaiser Permanente note R1's opiate abuse due to back pain. Interview with R1 conducted on 3/20/2021 indicates that facility had staff administer medication to R1 and R1 was satisfied with the facility's administration of medication.

Upon review of Centrally Stored Medication form and MAR for R1, the facility has documented that they were providing medications to R1 as prescribed.

Allegation: Staff did not assist resident with ADLs.

Relevant party indicated that R1 did not receive assistance with hygiene, including brushing their teeth. Needs and Services Plans dated 1/18/2020 and 1/11/2021 stated that R1 is capable of communicating care needs verbally. Preplacement Appraisal Information for R1 dated 1/10/2020 stated that R1 “can take care of [their] own teeth, but needs help showering and dressing.” Needs and Services plan dated 1/18/2020 states that R1 is independent with oral care needs. Needs and Services plan dated 1/11/2021 states that R1 needs assistance of 1 person to complete oral care needs.

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 27-AS-20210225150536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUNRISE OF ROCKLIN	FACILITY NUMBER: 315001968
	VISIT DATE: 03/25/2022

NARRATIVE

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Needs and Services plan dated 1/18/2020 and 1/11/2021 state that R1 needs 1 person assist with grooming, dressing, and toileting, as well as a chair to assist with bathing. Facility charting notes indicate that R1 did not refuse any of the following services prior to leaving the facility and all services pertaining to grooming and hygiene were provided. Hospice notes provided by Suncrest Hospice indicate that no abuse or neglect by the facility was observed while receiving hospice care.

Interviews conducted with staff (S1, S2) on 3/24/2022 indicated that facility includes brushing teeth with hygiene responsibilities for residents. Interviews with S1 and S2 also indicate that all residents have scheduled showers. Interviews conducted with residents (R2, R3) on 3/24/2022 stated that ADLs are being addressed and care needs are being met.

Relevant party indicated that facility staff did not seek whether R1 needed assistance with eating. Preplacement Appraisal Information for R1 dated 1/10/2020 states that R1 “only needs…food cut up…Can’t use knife anymore.” Physician’s Report LIC 602 for R1 dated 1/17/2020 states that R1 is able to feed self. Interviews conducted with staff (S3, S4) on 3/16/2022 stated that they delivered food to R1 and would assist R1 with feeding and cutting food if requested by R1.

Interview conducted with Dining Services Coordinator (S5) on 3/24/2022 stated that kitchen staff utilize a Point Click Care (POC) system which instructs the kitchen staff on food modifications for residents. If resident has a modification indicated on care plan, kitchen staff should be notified and prepare food according to each resident’s modifications before serving food, including cutting up food.

Interview with R1 conducted on 3/20/2021 indicates that, at the time R1 was living at the facility, R1 did not need assistance with being fed.

Allegation: Facility did not manage resident's incontinence needs.

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 27-AS-20210225150536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SUNRISE OF ROCKLIN	FACILITY NUMBER: 315001968
	VISIT DATE: 03/25/2022

NARRATIVE

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Interview with Executive Director, Rouzbeh Moradhasel, on 3/3/2021, indicated that, when R1 was experiencing multiple bowel movements on 2/16/2021, all of R1’s belongings were already transferred to new facility and Executive Director was unsure of what condition R1 was in upon admission to new facility. Facility charting notes indicate that R1 did not refuse any incontinence care services provided by the facility prior to leaving the facility. Hospice notes provided by Suncrest Hospice indicate that there were no observations that facility was not providing incontinence care to R1.

Interviews conducted with staff (S1, S2) on 3/24/2022 indicated that staff conduct regular checks (1-2 hours or as needed) for residents receiving continence care. Interviews with S1 and S2 indicate that residents are offered showers if they are found to have soiled themselves.

Interview with R1 conducted on 3/20/2021 indicates that R1 was experiencing constipation while living at the facility and nursing staff assisted with constipation by providing medication to resolve symptoms.

Allegation: Facility did not provide food options for resident.

LPA inspected food supply at the facility during visit conducted on 3/16/2022 and observed a 2-day perishable and 7-day non-perishable food supply at the facility. LPA reviewed facility’s menu and observed multiple food options for the residents.

Based on interviews conducted by the Department and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with RCD and a copy of this report was provided to the facility. The signature of the RCD on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 8