342700705-6-27-2024-59-AS-MSEY-D6TMEM-20240703093257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700705
Report Date: 06/27/2024
Date Signed: 06/27/2024 03:15:58 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
06/10/2024 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240610083421

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: 65	DATE:	06/27/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Karen Padilla, Director of Nursing		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not comply with infection control requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation and deliver findings to a complaint received on 6/10/24. LPA met with Karen Padilla, Director of Nursing (DON), and stated the reason for today's inspection. LPA met with Daniel Torgersen, Assistant Administrator, later during the inspection.

During today's inspection, LPA interviewed (3) staff who work on the Assisted Living side, resident (R1) and obtained an update from the DON regarding the recent scabies outbreak. During the course of the investigation, LPA interviewed the Assistant Administrator, DON, several residents, and the Ombudsman. LPA reviewed documentation submitted to the Department pertaining to the scabies outbreak and also communicated with local public health by e-mail.

The results of the investigation are as follows:

*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: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

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-20240610083421

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: 06/27/2024

NARRATIVE

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9099C-1... Allegation: Staff did not comply with infection control requirements. The allegation states the facility was not taking the necessary precautions regarding the scabies cases amongst residents, which has led to its spread to multiple residents (6-8), posing a safety risk. The allegation also states that some staff were not notified until they reported to work, and that residents’ family members were not notified timely.
The Department was notified that the Ombudsman visited the facility on Thursday, 6/6/24, to speak to resident (R1) after receiving a report (R1) had scabies. The Ombudsman indicated there were no gowns or any warning on (R1's) door that (R1) had Scabies or any infectious disease.

Department records show the facility reported the scabies outbreak by phone later in the day on 6/6/24 (4:44 pm), following the inspection from the Ombudsman, and the Department sent a follow up e-mail to the DON on 6/7/24 (9:26 am), confirming the facility reported one resident-case of scabies and one possible case, treated, and additional residents showing signs of itching.

The Department received a completed template on 6/7/24 (3:18 pm) – reporting 1 confirmed case, 1 suspected case and 3 (R3, R4 and R5) residents with symptoms of itching. Also received on 6/7/24, were (2) incident reports for residents (R1) and (R2) who reportedly contracted scabies on 5/22/24 and on 5/15/24, respectively.

The incident reports note that local public health was notified/contacted; however, the local public health department confirmed that they did not receive a confirmed voice message from the facility until 6/10/24 (11:34 am). LPA provided e-mail contacts for local public health to the facility on 6/11/24 and then provided e-mail contacts for the facility to local pubic health on 6/12/24. LPA was included on an e-mail sent from local public health to the facility, on 6/12/24 (11:00 am), acknowledging a confirmed voice message had been received by the facility on 6/10/24.

The e-mail sent by local public health on 6/12/24 included resources for scabies treatment and prevention and confirmed that "Scabies is reportable if two or more confirmed cases or 1 confirmed case and at least 2 suspect cases occurring among patients/residents, HCP, visitors, or volunteers during a 6-week period should be considered an outbreak for reporting purposes"

*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: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20240610083421

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: 06/27/2024

NARRATIVE

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9099C-2... On 6/10/24, The DON stated she was currently in the process of finishing the first round of treatment (creme) for the remaining Assisted Living residents, and the second treatment was scheduled for later that week. Additionally, the DON and Assistant Administrator stated they have already sprayed both the individual rooms and the common areas, earlier that day (6/10/24). LPA observed a pest control company arrive to the facility to spray at 6/10/24 (1:00 PM).

Per the DON, the PPE cart was not placed out near the positive residents' rooms until 6/10/24, and it was placed near (R2')s room, who was the first resident to break out with scabies, on/around 5/15/24. On 6/10/24, LPA observed the PPE cart to be placed near (R2's) room, and a second PPE cart to be near (R6's) room in the Memory Care Unit. There were no other residents who contracted scabies in the Memory Care Unit.

LPA observed signage referring to the scabies outbreak to be posted outside the front entrance on 6/10/24, at 1:00 pm, but received information the sign had just been placed outside the door earlier that morning. LPA did not observe a sign regarding the scabies outbreak posted outside the front entrance on 6/27/24, and the DON stated the sign was moved to the lobby area.

On 6/10/24, The Assistant Administrator indicated that families of residents who tested positive were notified, and the DON confirmed on 6/27/24, that these families were called on 6/7/24, and a follow up letter was sent to every responsible person on 6/21/24, informing of the recent scabies outbreak, The DON stated to LPA on 6/27/24 that there is only (1) resident (R7) who is still recovering, and all other residents have recovered.

On 6/25/24, an updated line list was faxed to the Department. The line list was provided by local public health and contained information related to (8) residents in ALU who contracted scabies. The list also shows (19) additional residents from ALU who were treated as precautionary measures on 6/8/24 and 6/9/24.

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: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20240610083421

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: 06/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/28/2024 Section Cited CCR 87470(c)(1)(A)(2)	1 2 3 4 5 6 7	87470 Infection Control Requirements -(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1)The Infection Control Plan shall include all of the following:(A) Identification of a staff position to perform the duties of an Infection Control Lead for the facility. 2. A description shall be included of how the Infection Control Lead shall be trained by a medical professional, local health official, health department, or other research-based medical authority that provides infection control training that will include enforcement of the Infection Control Plan. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee/Administrator agree to review their Infection Control Plan and provide staff training on the necessary infection control protocols to be taken when there is an outbreak of a contagious infection/disease, etc.
	8 9 10 11 12 13 14	Based on interviews and observations, the facility did not ensure that all its infection control protocols, including placing PPE carts near affected resident rooms, posting signage where needed, and consulting with the local public health department, were followed timely, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Documentation of completed training to be submitted by tomorrow, 6/28/24. Facilty also agrees to provide documentation of clearance from local public once all cases have cleared.
Type B 07/11/2024 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	87211 Reporting Requirements - (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee/Administrator agree to review Regulation 87211 with reporting managers and staff and submit a signed statement to the Department that training has been completed. Due by 7/11/24.
	8 9 10 11 12 13 14	Based on documentation reviewed, the facility did not ensure that the inifial (2) scabies cases were reported timely to the Department and to local public health, by 5/23/24, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC9099 (FAS) - (06/04)

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