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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700705
Report Date: 02/20/2024
Date Signed: 02/20/2024 05:12:43 PM


Document Has Been Signed on 02/20/2024 05:12 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:SUMMERHAYS, CALEBFACILITY TYPE:
740
ADDRESS:7241 CANELO HILLS DRIVETELEPHONE:
(916) 722-2800
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:78CENSUS: 40DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Daniel Torgensen , Assistant Administrator TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Daniel Torgensen , Assistant Administrator, and explained purpose of inspection. The facility is licensed for 78 bedridden residents there is an approved hospice waiver for 10 residents. There are currently (7) residents on hospice. There is currently a pending change in ownership.

LPA and the Assistant Administrator toured the interior and exterior of both the Assisted Living and Memory Care units, including the common areas, several resident rooms with a shared bathroom, medication room, dining room, activity room, salon, kitchen and laundry room. LPA observed the facility to be clean, in good repair, odor free and the bathrooms to have paper towels, soap, and trash cans with lids. There are 20-second hand-washing posters throughout. Fire extinguishers observed throughout and were last serviced on 6/6/23.Inside temperature measured 71*F and hot water measured 106*F in (3) resident rooms on Assisted Living. Activity calendars and menus are posted. Toxins are locked in the laundry rooms.
There is 2+day perishable and 7+day non-perishable supply of food. Daily documentation is maintained for refrigerator/freezer/water temperatures and there are designated tasks posted for each shift in the kitchen. An outside company was on-site to complete a final inspection related to fire codes. All required postings are in the common area. The Infection Control Plan and Emergency Disaster plans were reviewed/approved.

LPA reviewed (6) resident files in Memory Care and (12) resident files in Assisted Living. Files were organized and complete and all care plans were current. There were (3) physician's reports that need updating. Medications were reviewed for (2) residents in each unit and no discrepancies were found. Current documentation is maintained and the facility scored 98% on a recent medication audit. (15) staff files were reviewed. All staff have current First Aid/CPR and are regularly completing required initial/continuing training via an approved on-line vendor. All staff is cleared/associated. Copy of current liability insurance obtained. LIC500 and LIC308 to be submitted by 2/27/24.
Per California Code of Regulation, Title 22, Division 6, Chapter 8, the following (1) deficiency was observed. Citation is 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: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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 02/20/2024 05:12 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: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
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:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in (3) out of (18) resident physician's reports, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2024
Plan of Correction
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Licensee/Administrator agree to request an updated physician's report from the doctor for residents (R1, R2 and R3) and submit the report to the Department by 3/5/24. Licensee/Administrator agree to request an extension if one is needed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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