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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700705
Report Date: 05/27/2021
Date Signed: 05/27/2021 01:39:57 PM

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:SUN OAK ASSISTED LIVINGFACILITY NUMBER:
342700705
ADMINISTRATOR:KEY, KAYEFACILITY TYPE:
740
ADDRESS:7241 CANELO HILLS DRIVETELEPHONE:
(916) 722-2800
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:78CENSUS: 51DATE:
05/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kaye Key, AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Bethany Huusfeldt-Mirlohi arrived unannounced to deliver findings for complaint. LPA met with administrator Kaye Key during today’s inspection.
In the investigation of the complaint the Department found that facility failed to seek medical attention for R1 after she sustained multiple unwitnessed falls. File review documents show that R1 sustained unwitnessed falls on 12/21/2020, 12/23/2020, and 12/30/2020. R1 was initially independent with walking, transferring, and toileting. After the fall on 12/23/2020, R1 was unable to walk and had to use a wheelchair. Staff were required to assist with ambulation and transfer her into a wheelchair. The alert charting notes document on 12/30/20 and 1/2/21 R1 complained of back pain post the fall on 12/23/2020. The alert charting notes document on 12/30/20, 12/31/20, 1/1/21,1/2/21, and 1/3/21 resident was given PRN pain medication due to residents complaints of pain.
Facility staff reported that resident had a significant change of condition following the falls. Staff stated resident was initially independent with walking, transferring, and toileting. Staff stated after the falls Helen was unable to walk and had to use a wheelchair. In addition, staff stated resident was unable to transfer herself in and out of bed, required staff assistance, and she chose to stay in bed most of the day. Staff reported that resident did not complain of pain to her back after the falls. Alert charting notes and medical records documenting a couple of occasions when resident complained of back pain prior to 1/4/2020.

Continuation on 809-C.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SUN OAK ASSISTED LIVING
FACILITY NUMBER: 342700705
VISIT DATE: 05/27/2021
NARRATIVE
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Staff reported that they sent a fax to residents’ doctor to notify them of the falls. Physician advised that resident be seen at an urgent care for evaluation. Staff reported that medical attention was not sought for resident because of R1’s responsible party(RP) refused for staff to call emergency services and send resident to hospital. Alert charting notes indicate on 12/30/20 staff reported to RP the doctor orders to be seen at Urgent care and RP declined. It is documented R1 was then found the same day on 12/30/20 at 5:00 pm on the floor and medical attention was not sought. File review documents and staff statements prove that facility staff noticed resident had significant changes in condition after her fall on 12/23/2020 and 12/30/2020 and facility failed to seek appropriate medical attention. Deficiencies will be cited on 809-D.

You are hereby notified that a civil penalty of $500.00 is assessed for a violation that resulted in serious bodily injury/serious injury of a client, or that constitutes physical abuse of a client.

The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of R1’s sustaining a fracture (serious bodily injury) while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SUN OAK ASSISTED LIVING
FACILITY NUMBER: 342700705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2021
Section Cited

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87465(g) Incidental Medical and Dental Care Services
The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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This requirement is not met as evidenced by: Based on interviews and record review the licensee did not seek medical attention in a timely matter which poses an immediate health and safety risk to the residents.
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Document was amended to reflect updated POC due date.

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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2021
LIC809 (FAS) - (06/04)
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