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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700705
Report Date: 10/25/2023
Date Signed: 10/25/2023 05:33:09 PM


Document Has Been Signed on 10/25/2023 05:33 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 31DATE:
10/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Daniel Torgersen, Asst Administrator and Aida Ventoso, Care CoordinatorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint and met with Daniel Torgersen, Assistant Administrator, and explained purpose of inspection. LPA met with Aida Ventoso, Care Coordinator, later during the inspection.

While reviewing resident Physician Reports (LIC602) in the Memory Care Unit, LPA observed that (2) of (8) resident reports were completed more than (12) months ago and had expired. (See citation issued on the 809D page)

LPA reviewed a quarterly medication audit report, completed on 9/25/23, and observed there to be areas where deficiencies were observed related to the following:
  • Infection Control- hand hygiene was only completed at the end of the med pass with soap and water, and the same pair of gloves was used while administering medications to multiple residents- Recommend completing hand hygiene before and after each resident contact, per CDC guidelines (See citation issued on the 809D page)



Per California Code of Regulations, Title 22 Division 6, Chapter 8, the following (2) citations are issued on the 809D page.

Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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Document Has Been Signed on 10/25/2023 05:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SUN OAK ASSISTED LIVING
FACILITY NUMBER: 342700705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
87470(B)(3)

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87470 Infection Control Requirements
(B)Hand hygiene shall be conducted as follows: 3. Before and after assisting with medications. This requirement is not met as evidenced by:
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Licensee/Administrator agree to conduct staff training on the importance of hand hygiene, using Regulation 87470 as a training resource.

Copies of scheduled training due to the Department by 10/26/23 and copies of signed agenda/attendees due by 10/31/23.
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Based on review of the quarterly pharmacy audit, conducted on 9/25/23, the Licensee did not ensure that a staff Med-Tech did not complete hand hygiene before and after each resident when administering medications, which poses an immediate health and safety risk to residents in care.
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Type B
11/08/2023
Section Cited
CCR87705(c)(5)

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
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Licensee/Administrator agree to obtain an updated physician's report for (R2) and (R3) and provide a copy to the Department by 11/8/23.
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Based on record review, the Licensee did not ensure that (2) of (8) Memory Care residents had an current physician's report (LIC602), completed within the last (12) months on file, which poses a potential health and safety risk to residents in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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