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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700705
Report Date: 05/01/2024
Date Signed: 05/01/2024 05:54:55 PM

Unsubstantiated


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
02/26/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240226113626
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: 49DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Daniel Torgersen, Assistant AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff does not provide the residents with adequate meal services.
Staff neglect is resulting in residents developing pressure injuries.
Staff leave the residents soaked in urine.
Staff are not qualified.
Staff does not maintain resident records up to date.
Staff does not ensure that residents are seen/re-evaluated by their physicians in a timely manner.
Staff does not ensure that residents' care conferences are being held.
Residents are admitted that require a higher level of care.
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 2/26/2024. LPA met with Daniel Torgersen, Assistant Administrator and Karen Padilla, the current Director of Nursing, and stated the reason for the inspection.

During the course of the investigation, LPA interviewed the prior Director of Nursing, Maintenance Director, (4) staff and (4) residents. LPA reviewed (8) resident files, including physician's reports, care plans and home health notes. LPA also reviewed documentation for resident (R1) and (R2). LPA also toured the Assisted Living side (two times) and Memory Care side of the community as well as the main kitchen.

The results of the investigation are as follows:

cont on 9099C-1...

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (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 5
Control Number 59-AS-20240226113626
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-1.. Allegation: Staff does not provide the residents with adequate meal services. Complaint alleges Meal services are lacking and late, never on time with inadequate staffing.

All staff interviews indicated that meals are served timely to residents with one staff stating the "menu has changed but there is no problem with serving food late". Residents can request seconds or a change in entree. Staff interviews also confirmed that if the culinary staff are short that day, other staff, including managers, will assist by setting the tables and serving food. LPA observed non-culinary staff assisting on 5/1/24 at 4:00 pm to prepare for dinner.

The Assistant Administrator stated staff is "on time and not late", and snacks are available all day, including after the kitchen closes at 7:30 pm. Also food orders are placed Tuesdays and Fridays and are delivered on Wednesdays and Saturdays. On 3/5/24, LPA and the Ombudsman toured the main kitchen and observed diet orders posted for all residents, including those in Memory Care, where all food is prepared. LPA observed the current's week menu posted along with an additional (3) weeks, as the menus are rotated, and sufficient 2+ perishable and 7+ non-perishable supply of food was observed in the main kitchen.

Resident interviews were conducted on 3/5/24.. One resident stated she has "no complaints" about the food it is, "served on time", and she is served a variety of food and they are good about fixing it. This resident indicated the food service has been the same the last couple of weeks. Another resident stated dinner is always served timely, at 4:30 pm. A third resident stated the food is "excellent, very tasty and good" and is served timely. A fourth resident confirmed staff is " still serving good food and it's on time", and asserted "I think the food got a little better"- "taste is better now- it was too much gravy before".

On 5/1/24,LPA observed residents to be seated at the dining tables at 4:30 pm with beverages already served and staff beginning to serve the dinner plates. Many residents had finished eating their dinner by 5:15 pm.

Based on information obtained, LPA Finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

cont on 9099C-2...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (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 5
Control Number 59-AS-20240226113626
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... Allegation: Staff neglect is resulting in residents developing pressure injuries. Complaint alleges Facility takes in residents that require high levels of care and leaves them in bed to develop sores.

Interviews revealed that the only resident who recently had a pressure sore is resident (R2). LPA reviewed (R2''s) file and noted the initial care plan, dated 4/26/22, notes resident had “a left buttock stage 2 pressure ulcer in healing stage” and resident would be receiving home health wound care nursing until the wound is healed. Resident’s initial and current LIC602, dated 4/25/22, notes resident has a history of skin breakdown and currently has breakdown on the right and left buttock and to triad daily. Resident does not have a diagnosis of Dementia but needs assistance with dressing/grooming due to lower body dressing.

Home Health notes document that wound care was provided starting on 6/5/23 for a Stage 2 bilateral buttock pressure injuries. The injuries are noted to have improved and were staged as I and II on 6/27/23 and continued at these stages through 10/25/23. Notes show that on 11/10/23 a new wound was observed on the right great toe and there were pending orders. Subsequent notes for November 2023 indicate the wounds were healing well and on 12/6/23, nurse notes document that “skin intact”, and there are no wounds or open areas as of 12/6/23”.

This resident was admitted to the facility on/Around April 2022. The facility is licensed to admit 78 bedridden residents, 20 of whom may be under hospice care.

Based on information obtained, LPA Finds the allegation to be UNSUBSTANTIATED-



Allegation: Staff leave the residents soaked in urine. Allegation states staff are leaving residents soaked in urine due to calls outs and inadequate staffing.

All staff interviews indicated that residents are checked regularly, every 2 hours, at least, and provided incontinent care, if needed. LPA toured the Assisted Living side of the community on 3/5/24, and on 4/25/24 and did not observe any incontinent odors to be present. LPA toured the Memory Care side on 3/5/24 and also did not observe any incontinent odors to be present.

Based on information obtained, LPA Finds the allegation to be UNSUBSTANTIATED-

*cont on 9099C-3...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (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 5
Control Number 59-AS-20240226113626
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-3.. Allegation: Staff are not qualified. Complaint alleges the Assistant administrator is not certified.

The Assistant Administrator,Danny Torgersen, stated he took the RCFE Admin test during the second week of October, 2023 and passed. Per Department website, Danny has a pending RCFE Administrator #6070172740 as of 10/24/23, and has been acting as Assistant Administrator since on/around November 2023 with oversight from Caleb Summerhays, who has RCFE Adminstrator certificate #6060941740- that is currently pending renewal with the Department (exp 11/14/23).

Several staff were interviewed and confirmed they regularly complete required training to work as a caregiver, Med-Tech, culinary, maintenance or other staff. Relias records were reviewed in February 2024, at the annual inspection, and confirmed that staff is regularly completing any required course work.

LPA and the Assistant Administrator also discussed how the menus are prepared by a dietician, through an outside company, and the facility has had this support service, as required, for a facility licensed for (50) or more residents, for many years. Additionally, a dietician was on site today to conduct a "soft audit" and spent (4) hours discussing topics such as: Food Preparation and Meal Service, Cleaning and Sanitation, Food Sanitation/Safety/Storage, Dietary Management, Nutrition Care and Equipment.

Based on information obtained, LPA Finds the allegation to be UNSUBSTANTIATED-


Allegation: Staff does not maintain resident records up to date. Allegation states resident physician report and care plans out of date for many of residents.

On 2/20/24, during an annual inspection, (18) resident files were reviewed and (3) were found to not have an updated/current physician’s report. A citation was issued at that time, on 2/20/24. On 4/15/214, LPA reviewed (7) resident files from Assisted Living Unit and observed all physician reports (LIC602) to be current.

Based on information obtained, LPA Finds the allegation to be UNSUBSTANTIATED-


cont on 9099C-4...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (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: 4 of 5
Control Number 59-AS-20240226113626
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-4... Allegation: Staff does not ensure that residents are seen/re-evaluated by their physicians in a timely manner. Residents are not routinely seen by physicians nor re-evaluated in a timely matter.

On 2/20/24, during an annual inspection, (18) resident files were reviewed and (3) were found to not have an updated/current physician’s report. Care plans were current in the files reviewed. A citation was issued at that time, on 2/20/24. On 4/15/214, LPA reviewed (7) resident files from Assisted Living Unit and observed all physician reports (LIC602) to be current.

Based on information obtained, LPA Finds the allegation to be UNSUBSTANTIATED-



Allegation: Staff does not ensure that residents' care conferences are being held. Allegation states Care conference are not held on ongoing basis as required.

LPA reviewed (7) resident files from ALU on 4/15/24 and observed all care plans to have a signature by both the responsible person/resident and a facility staff person. On 4/15/24, the Director of Nursing stated that all care plans were in the process of being reviewed and updated, if needed, to ensure they are current and reflect resident's needs. On 2/20/24, during an annual inspection, multiple resident files were reviewed and found to contain a current care plan with the responsible person's signature.

Based on information obtained, LPA Finds the allegation to be UNSUBSTANTIATED-


Allegation: Residents are admitted that require a higher level of care. Allegation states Facility takes in residents that require high levels of care, specifically (R1)

All staff indicated that residents who are admitted are appropriate for the community, including resident (R1). Resident (R1) was admitted on/around January 2024 and has a diagnosis of Cerebral Palsy. This resident is a two-person assist and was admitted to hospice care on 2/7/24. (R1) is unable to ambulate. The Facility license is approved for (78) bedridden residents.

Based on information obtained, LPA Finds the allegation to be UNSUBSTANTIATED-



Exit interview. Copy of report provided to the Assistant Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (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: 5 of 5