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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700705
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:50:13 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
09/13/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240913125033
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:0CENSUS: 66DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Danny Torgersen, Co- Administrator TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff did not assist with resident's medication refills.
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 9/13/24. LPA met with Karen Padilla, Director of Nursing (DON), and stated the reason for today's inspection. LPA later met with Daniel Torgersen, Assistant Administrator.

During the investigation, multiple interviews were conducted with staff and residents and documentation was reviewed that is related to resident (R1), including the physician's report, appraisal, shower documentation, charting notes and Medication Administration Records (MAR) for months August, September and October 2024. The results of the investigation are as follows:

Resident (R1) moved to the facility on/around 12/27/23. (R1’s) physician report (dated 12/21/23) and appraisal (dated 3/7/24) notes resident has a primary diagnosis of COPD, and a secondary diagnosis of chronic respiratory failure, spinal stenosis, and hypertension.(R1) does not have a diagnosis of Dementia, or Mild Cognitive Impairment, is alert and oriented, shows no signs of confusion/forgetfulness and can communicate her needs.
*cont on 9099C-1...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 7
Control Number 59-AS-20240913125033
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: 12/12/2024
NARRATIVE
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9099C-1.. Resident is incontinent and requires assistance with bathing, dressing, toileting, medication management, uses a wheelchair and needs a 1-2 person assistance sometimes when transferring.

Allegation: Facility staff did not assist with resident's medication refills. Allegation states on 9/13/24, resident (R1) had been out of her medications for about a week and that staff will not assist with getting her medication refills.

(R1) stated on 9/17/24 that the facility let her medications expire because they "couldn't get a driver" and she missed (5) medications for about a week, but she is currently receiving her medications, as scheduled, three times daily, at 9 am, 5 pm and 8 pm. The Director Of Nursing (DON) stated on 9/17/24 that (R1) missed a PRN medication, Norco, for a week, but currently has a supply, stating that they did not know the medication was ready to be picked up.

The Administrator stated on 9/17/24 it's "customary to use the van on Mondays and Wednesdays for medical appointments" and he, the DON, and Med-Techs have picked up meds for (R1) before, adding that (R1's) health care plan will mail the medications, but it cost more, and (R1) won't agree to change her pharmacy.

September MAR shows there Norco was not administered from 9/1/24- 9/6/24 but resident received a PRN dosage daily from 9/7/24- 9/11/24, on 9/13/24, 9/17/24, from 9/19/24 through 9/21/24, on 9/24/24 and on 9/30/24. September MAR shows resident received scheduled Tylenol 500mg, 3 times daily, for each day of the month, received as PRN dosage of Acetaminophen 500 mg on 9/15/24, and all scheduled medications were initialed as given in September.

There are no resident charting notes documenting that medications were not given or filled for a week on/around 9/13/24. One Med-Tech staff stated resident did not have a refill supply of Hydrocodone-Acetaminophen 10-325 mg (Norco) on hand, for one day, but was not sure if that was in the month of October or November, 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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20240913125033
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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2024
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
This requirement is not met as evidenced by:
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Licensee/Administrator agree to conduct follow- up training with staff to better monitor when refills are available for pick up with (R1) or any other residents.

Documentation of training to be submitted to the Deparment by 12/31/24.
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Based on interviews conducted, the Licensee did not ensure that an ordered refill for (R1's) PRN order of Hydrocodone-Acetaminophen 10-325 mg, was picked up timely, on/around 9/13/24, to ensure the medication was always available should the resident request it, which posed an immediate health and safety risk to residents in care.
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The facility has a full-time drive since the beginning of November 2024. The driver can go Monday- Friday.
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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: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
09/13/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240913125033

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:0CENSUS: 66DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Danny Torgersen, Co- Administrator TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff are not providing resident’s medication as prescribed.
Facility staff are not meeting a resident's showering needs.
Facility staff are not meeting a resident's changing needs.
Facility staff did not safeguard resident's personal belongings.
Facility staff are not properly addressing outbreaks at the facility.
INVESTIGATION FINDINGS:
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During the investigation, multiple interviews were conducted with staff and residents and documentation was reviewed that is related to resident (R1), including the physician's report, appraisal, shower documentation, charting notes and Medication Administration Records (MAR) for months August, September and October 2024. The results of the investigation are as follows:

Allegation: Facility staff are not providing resident’s medication as prescribed. Allegation states staff are not assisting residents with their medications.

Resident (R1) confirmed on 9/17/24 she is currently receiving her medications, as scheduled, including Acetaminophen 500 mg, three times daily, at 9 am, 5 pm and 8 pm. The August and October MAR show staff had initialed that each dosage was given, as ordered, with a few boxes not initialed. The September MAR was complete with staff initials entered each time a scheduled dose, or PRN medication was given. The additional information required for a PRN was also documented for each of these three months reviewed.
*cont on 9099A-C1...
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: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20240913125033
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: 12/12/2024
NARRATIVE
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9099A-C-.. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED-

Allegation: Facility staff are not meeting a resident's showering needs. Allegation states staff are not assisting residents with their showers.

Resident (R1's) appraisal, dated 3/7/24, notes resident may refuse showers depending on her mood.

Both the DON and the Care Coordinator, Kayla, confirmed on 9/17/24 that (R1) receives regular showers and prompt assistance from staff when using the call button. The DON also stated that staff are continuing to ask (R1) to sign every time a shower is offered and if she accepts or declines.

One staff stated that (R1) can be difficult sometimes, as she "would change her mind regarding showers", so staff began asking (R1) to sign a shower form around June 2024. Additionally, staff will offer showers to (R1) after morning medications have been given. A second staff stated if (R1) refuses a shower she will request a bed bath.

(R1) stated to LPA on 10/15/24 that she has no issues with showering and things improved once a particular staff left, and the DON and the Care Coordinator are monitoring her. (R1) stated to LPA again on 12/12/24 that she receives regular bed baths. LPA reviewed shower documentation for the following days: 8/17/24 (12:30 pm); 8/21/24; 8/24/24; 8/28/24; 8/31/24; 9/4/24; 9/7/24; 9/11/24; 9/18/24 (10:50 am). On each form, it was noted that (R1) signed for a "Hands-on shower with staff help".



(2) other residents were interviewed who reside in Assisted Living and both residents indicated they are given showers as scheduled, twice weekly, and they do not have any concerns.

Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED.



Allegation: Facility staff are not meeting a resident's changing needs. Allegation states staff are not assisting residents with changing needs.

(R1) stated on 9/17/24 that the "pm" staff, who work from 2:00 pm - 10:00 pm, have attitude and don't change her diaper every 2 hours. One staff stated (R1) is checked frequently and asked if she needs changing, and (R1) will also let staff know if she needs assistance. (2) other residents who interviewed.
*cont on 9099A-C-2...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20240913125033
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: 12/12/2024
NARRATIVE
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*9099A-C-3... One resident indicated she receives assistance in the bathroom timely, but she called staff one time for her roommate that had been waiting for assistance for a while in the bathroom. Another resident stated she is independent with toileting. (R1) stated to LPA on 10/15/24 that she has no issues with staff changing her timely now, and things improved once a particular staff left, and the DON and the Care Coordinator are monitoring her. (R1) stated to LPA again on 12/12/24 that she has been receiving regular incontinent care.
Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED-

Allegation: Facility staff did not safeguard resident's personal belongings. Allegation states that resident’s clothing and other personal items, such as the bedside toilet and walker, were taken from resident’s room. It is not known if the items were taken by staff or other residents.

On 9/17/24 (R1) stated she had a shower chair but it disappeared and wasn't in the bathroom the last time she took a shower. (R1) also stated she has had clothes go missing as well as nice perfume. On 9/17/24, the Ombudsman confirmed that the shower chair was currently in the bathroom. LPA observed it to be in the bathroom on 9/17/24, 10/15/24 and on 12/12/24.

One staff stated they are not aware of any of (R1's) items going missing; however, the shower chair could have been moved to another resident's room temporarily.

A second staff stated she is not aware of any (R1's) items going missing, including a jacket and explained that sometimes a resident will tell a caregiver if an item is missing. This staff stated the caregiver will then report it to the Med-Tech, who will note the missing item in Alert Charting but was not sure if there is a specific book to log a missing item.

Two additional residents indicated they have not had any items disappear.

(R1) stated to LPA on 12/12/24 that her red jacket, Windsong perfume or white jumpsuit were not returned to her after they disappeared on/around January 2023. Two blouses disappeared in the laundry, but her name was not on it. (R1) stated she reported the items missing to staff and does not believe she, or other residents completed an Inventory of personal items when moving in. DON to ensure all residents continue to keep a completed Personal Inventory upon moving in.

Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED-

*cont on 9099A-C-4..

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20240913125033
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: 12/12/2024
NARRATIVE
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9099A-C-4... Allegation: Facility staff are not properly addressing outbreaks at the facility. Allegation states the facility previously had a scabies outbreak and resident (R1) has continued to have a rash after multiple skin treatments.

Charting notes from 3/6/24 note resident was "having rashes on her stomach and back and is complaining of itching and burning where the rashes are located". April notes document resident was given prescribed cream and antibiotics for the rash and itching. On 6/6/24, resident was sent to the emergency room prescribed a new antibiotic for bronchitis. Notes from 7/3/24 say a hospital nurse contacted the facility to inform (R1) indicated she has rashes she states she has had since 2023 but the doctor does not think the rash is scabies but resident should be isolated for (3) days and treated with Permethrin. Notes document that resident continued to receive treatment and was on alert charting and isolation, until 7/12/24. Notes entered by the DON on 8/13/24 state (R1) complained of itchiness upon being assessed with a facility staff, and it is from the scabbed bumps randomly on her body. Resident allowed the DON to make her a dermatology appointment to be assessed.

Notes entered on 9/24/24 indicate that resident was transferred to the emergency room after a syncope episode when attending a medical appointment. Paramedics who transported her note (R1) had scabies. Resident returned to the community at 5:10 pm with a diagnosis of Scabies on the Scalp and given a prescription for a Nix treatment to the scalp and repeat in one week. The incident report submitted states (R1) received the initial treatment on 9/25/24 while in isolation. The DON confirmed the doctor only diagnosed scabies on (R1's) scalp and there were no scabies detected on her body. Two staff stated staff followed infection control protocols, including proper use of PPE, when (R1) had scalp scabies and no other residents acquired scabies during this time period. In July 2024, the community had a scabies outbreak involving multiple residents and staff. The Department received a complaint on 6/10/24 where the allegation of staff not following all aspects of its infection control policy was substantiated.

The facility sent (R1) to a doctor on many occasions, and different creams and treatments were given, since she first complained of itching and burning, and no other residents acquired scabies during this time.

Based on information obtained, the facility, LPA finds this 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.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7