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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700705
Report Date: 05/27/2021
Date Signed: 05/27/2021 01:38:01 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
03/12/2021 and conducted by Evaluator Bethany Huusfeldt
COMPLAINT CONTROL NUMBER: 27-AS-20210312090048
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
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kaye Key, AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of care and supervision resulting compression fracture vertebrae
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bethany Huusfeldt-Mirlohi arrived unannounced to deliver findings into allegation listed above. LPA met with administrator Kaye Key during today’s inspection.
The department investigated the allegation, “Lack of care and supervision resulting compression fracture vertebrae”. The department interviewed staff, R1, and reviewed R1’s facility documents and hospital records. R1 sustained a fall on 12/21/20, 12/23/20, 12/30/20. Prior to the fall R1 was able to ambulate with a cane independently. The department interviewed staff in which they stated R1 was independent with care and only needed stand by assist in the shower, and at times reminders to complete care. After the fall on 12/21/20, 12/23/20 and 12/30/20, staff stated resident had a change of condition. R1 was unable to walk, required a wheelchair, unable to transfer in and out of bed, and required staff assistance.
Contiutation on 9099-C.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
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
03/12/2021 and conducted by Evaluator Bethany Huusfeldt
COMPLAINT CONTROL NUMBER: 27-AS-20210312090048

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
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kaye Key, AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to report incident to resident's family and CCL
Lack of care and supervision resulting in dehydration resulting in hospitalization
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bethany Huusfeldt-Mirlohi arrived unannounced to deliver findings into allegation listed above. LPA met with administrator Kaye Key during today’s inspection.
The department investigated the allegation, “Facility failed to report incident to resident's family and CCL”. The department interviewed staff and responsible parties, and conducted a file review. Interviews with responsible parties indicate they were informed of R1’s fall in December 2020. In addition, records indicated facility informed R1’s physician of falls. Interviews with administrator indicate they did not report R1’s unwitnessed falls on 12/23/20 and 12/30/20 due to falls being non-injury falls. Due to information gathered LPA finds allegation to be UNFOUNDED.

Continuation on 9099-C.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20210312090048
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: SUN OAK ASSISTED LIVING
FACILITY NUMBER: 342700705
VISIT DATE: 05/27/2021
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
26
27
28
29
30
31
32
The department investigated the allegation, “Lack of care and supervision resulting in dehydration resulting in hospitalization”. The department reviewed hospital records and interviewed facility staff. Medical records from the emergency room document that R1 had a diagnosis of “syncope and collapse”. The cause of the syncope and collapse was not listed. It was reported that syncope episodes were common for R1. Labs were conducted and acetaminophen level were normal. Dehydration was not listed as a concern. Facility staff reported that they did observe symptoms of dehydration in R1. R1 was offered fluids multiple times during the AM and PM shifts. Due to the information gathered the department finds allegation to be UNFOUNDED.

Exit interview conducted.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20210312090048
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: SUN OAK ASSISTED LIVING
FACILITY NUMBER: 342700705
VISIT DATE: 05/27/2021
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
26
27
28
29
30
31
32
Facility documented 2 occasions when Helen complained of back pain. R1’s family took resident to their primary care physician on 1/4/21, in which R1 was then sent out to the hospital. CT scans diagnosed R1 with a “closed compression fracture of L2 lumbar vertebra”.
CCL reviewed facility records, and observed resident was classified as a fall risk. Fall prevention strategies noted that R1 must walk with a cane and that her apartment must be clutter free and well lit. The incident investigation report from the fall of 12/23/20 indicates that R1 was taking themselves to the bathroom when they tripped in the dark and fell. R1’s night light was on but the bathroom light was off. R1’s care plan was updated after their fall. Staff were required to assist R1 in a wheelchair to prevent falls and assist R1 with transfers. Staff were required to ensure that the bathroom light remained on at all times. The incident investigation report from the fall of 12/30/20 indicates that R1 attempted to transfer herself and fell.
Based on file review documents, it appears R1 had a significant change in condition after sustaining a fall. File review documents and staff interviewed indicate that R1 apartment is be well lit at all time. The bathroom light was not on at the time of the incident, only the night light was lit on 12/23/20 fall which resulted in R1’s fall. Allegation is found to be substantiated.

Citations issued on 9099-D.

Exit interview conducted and appeals rights printed and provided to administrator.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 27-AS-20210312090048
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: 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
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 in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, 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.
1
2
3
4
5
6
7
Administrator agrees to conduct a training with all staff about care plans and the importance of reviewing updated careplans and fall prevention plans.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on record review and interviews the licensee did not provide sufficient care and supervision which poses an immediate Health and Safety risk to residents in care.
8
9
10
11
12
13
14
Date of training and training material to be sent into CCL by 5/28/21.


Document was amended to reflect updated POC due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LIC9099 (FAS) - (06/04)
Page: 2 of 6