342700705-5-1-2024-59-AS-MSEY-D4ZP72-20240506110314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700705
Report Date: 05/01/2024
Date Signed: 05/01/2024 05:49:09 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2024 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240422104748

FACILITY NAME:	SUN OAK ASSISTED LIVING		FACILITY NUMBER:	342700705
ADMINISTRATOR:	SUMMERHAYS, CALEB		FACILITY TYPE:	740
ADDRESS:	7241 CANELO HILLS DRIVE		TELEPHONE:	(916) 722-2800
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	78	CENSUS: 49	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Daniel Torgersen, Assistant Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Illegal eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint investigation for a complaint received on 4/22/2024. LPA met with Daniel Torgersen, Assistant Administrator, and explained the purpose of the inspection.

During the course of the investigation, LPA interviewed the Assistant Administrator, (2) staff, the Ombudsman, (1) family member, and the social worker for (R1). LPA reviewed documentation pertaining to R1. The results of the investigation are as follows:

The allegation states that (R1) has resided in the facility for several months and has been sent to the emergency room, on multiple occasions, for displaying aggressive behaviors and agitation towards staff and other residents. Medication changes were made during many of the hospital visits. The facility initially refused to take resident back from the hospital, several times, but then did agree to after medication changes were made. On 4/19/24., resident was sent out again for aggressive behaviors, and the facility had stated resident cannot return under any circumstances.
*cont on 9099C-1...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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 4

Control Number 59-AS-20240422104748

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/01/2024

NARRATIVE

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909C-1... Resident (R1) moved to the community in December 2023 and was placed in the Memory Care Unit. Resident's Pre-appraisal, completed on 12/12/23, notes resident ambulates independently, can be confused at times, is easily redirected, has history of PTSD but shows no aggression, but can be anxious when thinking about the war. Resident's physician's report dated, 12/12/2023, notes resident also has a diagnosis of Dementia, hypertension, may wander and can be confused/disoriented due to cognitive decline; however, resident is able to follow directions and communicate his needs. Resident's care plan reflects that resident needs reminders for bathing, dressing, hygiene and assistance with medication administration.

Resident was sent to the Emergency Room multiple times from 1/10/24 through 4/19/24, due to showing agitation and aggressive behaviors, such as shouting, towards staff and residents. Resident was sent out (4) times in January 2024, (4) times in March 2024 and then (1) time, on 4/19/24. On 3/31/24, resident's doctor was spoken to ensure there was a medication change before allowing resident to return to the community. On 4/19/24, resident was sent out again for showing signs of agitation, and not allowed to return to the community due to these behaviors. Narrative Charting notes were reviewed from December 2023 through 4/19/24 when resident was sent to the Emergency Room. The notes consistently show staff documented that (R1) regularly showed agitated behaviors towards staff and other residents.

(R1's) social worker stated (R1) had some "confusion in the beginning but he hasn't hurt anyone" but doesn't like to wait. This individual stated she observed (R1) to be "agitated one time", has "never refused medications" per her knowledge, and she has also "never seen (R1) to be aggressive". The social worker stated (R1) will joke around and his "humor may scare residents". (R1's) family member stated resident definitely has anxiety and takes several medications to calm him.

The Assistant Administrator stated (R1) was aggressive with residents, staff and him prior to sending him out on 4/19/24. The Admission Director confirmed she was present on 4/19/24 and heard (R1) scream at a care staff. Care notes document (R1) became verbally aggressive and tried to be physically aggressive towards a care staff. A caregiver who was present confirmed she was called inappropriate names and resident was aggressive towards her, indicating resident's behaviors became increasingly worse from December 2023- April 2024. The Ombudsman stated the issue is "two-fold" and explained (R1) "acts fine at the hospital" and secondly "has a very short-term memory, so doesn't remember what he did (5) minutes ago.
*cont on 9099C-2...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20240422104748

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/01/2024

NARRATIVE

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9099C-2... The Assistant Administrator confirmed that a (30) day written eviction notice was not issued to (R1) and his responsible person, at any point prior to sending (R1) to the emergency room on 4/19/24, and refusing resident to return to the facility.

LPA and the Assistant Administrator discussed how a (30)-day written eviction notice should have been issued shortly after (R1) began showing increased agitation and aggressive behaviors towards staff and residents, on/around January 2024.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page.

Exit interview. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20240422104748

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/15/2024 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to read Regulation 87224 and submit a 30-day notice to the Department that should have been issued to (R1) and his responsible persons. Documentation due by 5/15/24.
	8 9 10 11 12 13 14	Based on interviews conducted, the Licensee did not ensure that a 30-day written notice was issued to resident (R1) when resident began showing aggressive behaviors towards staff and residents, which poses a potential health and safety risk to residents in care. (R1) was sent to the ER on 4/19/24 and was not permitted to return to the community due to aggressive behaviors.	8 9 10 11 12 13 14
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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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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