342700705-5-27-2021-27-AS-MSEY-C3EUR9-20210527154823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700705
Report Date: 05/27/2021
Date Signed: 05/27/2021 01:35:58 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
11/18/2020 and conducted by Evaluator Bethany Huusfeldt

COMPLAINT CONTROL NUMBER: 27-AS-20201118090830

FACILITY NAME:	SUN OAK ASSISTED LIVING		FACILITY NUMBER:	342700705
ADMINISTRATOR:	KEY, KAYE		FACILITY TYPE:	740
ADDRESS:	7241 CANELO HILLS DRIVE		TELEPHONE:	(916) 722-2800
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	78	CENSUS: 51	DATE:	05/27/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Kaye Key, Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Residents needs not being met.

INVESTIGATION FINDINGS:

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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.
LPA investigated the allegation, “Residents needs not being met”. LPA reviewed resident documents, interviewed staff and administrator during compliant investigation. LPA reviewed R1’s documents and found resident moved into the facility on July 2020. A preplacement assessment was completed in June 2020 indicating R1 had a cancer which was creating a painful sore on her body however R1 refuses treatment. A needs and service plan was completed for R1 indicating resident has sores on her face, her arms, and her legs that cause her quite a bit of pain. Care plan indicates staff are to observe and report pain levels to med tech. LPA reviewed R1’s LIC602, in which it indicated resident had no history of skin conditions and breakdowns.
Continuation on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (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)

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Control Number 27-AS-20201118090830

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

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LPA interviewed 8 staff members throughout investigation. 8 staff members stated R1 had a large sore on her leg, and R1 would complain of pain or groan of pain daily due to the sore on her leg. Interviews indicated residents' sore had a smell to it, and at times there was dried blood on the sore and on resident’s sheets due to R1 scratching the sore. Administrator and service coordinator indicated resident and family refused treatment. From the time of R1’s move in on 7/7/20 through 8/7/2020 there is no documentation showing communication to R1’s physician and no internal notes concerning R1’s sore. On 8/7/20 staff informed physician that resident had “bug bites” on her left thigh, however no mention of the large sore that was causing R1 pain. On 9/13/20 staff faxed doctor about R1’s pain to her legs and physician prescribed PRN Tylenol. On 10/8/20 facility requested homehealth for resident’s leg sores and homehealth was started on 10/27/20.
Due the information gathered from interviews and documentation review, R1 complained of pain daily from her sore on her leg. Staff heard complaints of pain from R1 in concerns to the leg sore, and at times an odor and dried blood would be seen. Staff did not properly seek medical attention for the sore until 10/8/21. LPA finds facility staff did not meet the needs of the resident; 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 Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (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)

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Control Number 27-AS-20201118090830

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 to conduct a training with all staff concerning documenting and communication with medical personnel. Date of training and training material to be sent into CCL by 5/28/21.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review and interviews licensee did not met residents needs which poses an immediate Health safety risk to residents in care.	8 9 10 11 12 13 14	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 Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (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)

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