342700705-4-19-2023-59-AS-BMII-CR2NZB-20230419105405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700705
Report Date: 04/19/2023
Date Signed: 04/19/2023 10:54:15 AM

Document Has Been Signed on 04/19/2023 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

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: 30	DATE:	04/19/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Aida Ventosa, Memory Care Manager		TIME COMPLETED:	11:10 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On April 19, 2023, Licensing Program Analyst (LPA) met with Memory Care manager of facility Sun Oak Assisted Living, Aida Ventosa, at approximately 10:15 AM. This report is for a Case Management visit to follow up on a deficiency cited during an inspection conducted on May 27, 2021, which determined that the facility did not seek medical attention in a timely manner for resident (R1). On May 27, 2021, The Department delivered complaint findings to the facility. During the investigation, the Department found that the facility failed to seek medical attention in a timely manner for R1 after they sustained multiple unwitnessed falls. The department interviewed staff, R1, and reviewed R1’s facility documents and hospital records. R1 sustained a fall on December 21, 2020, December 23, 2020, and December 30, 2020. Prior to the fall R1 was able to ambulate with a cane independently. The department interviewed staff in which they stated R1 was independent with care and only needed stand by assist in the shower, and at times reminders to complete care prior to falls. After R1’s fall on December 21, 2020, December 23, 2020, and December 30, 2020, staff stated resident had a change of condition. R1 was unable to walk, required a wheelchair, unable to transfer in and out of bed, and required staff assistance. Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SUN OAK ASSISTED LIVING	FACILITY NUMBER: 342700705
	VISIT DATE: 04/19/2023

NARRATIVE

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The alert charting notes document on December 30, 2020 and January 2, 2021, R1 complained of back pain post the fall on December 23, 2020. The alert charting notes document on December 30, 2020, December 31, 2020, January 1, 2021, January 2, 2021, and January 3, 2021, resident was given PRN pain medication due to residents’ complaints of pain. Staff reported that they sent a fax to residents’ doctor to notify them of the falls. Physician advised that resident was to be seen at an urgent care for evaluation. Staff reported that medical attention was not sought for resident because of R1’s responsible party (RP) refused for staff to call emergency services and send resident to hospital. Alert charting notes indicate on December 30, 2020, staff reported to RP the doctor orders to be seen at Urgent care and RP declined. It is documented R1 was then found the same day on December 30, 2020 at 5:00 p.m., on the floor and medical attention was not sought. R1’s family took resident to their primary care physician on January 4, 2021, in which R1 was then sent out to the hospital. CT scans diagnosed R1 with a “closed compression fracture of L2 lumbar vertebra”.

Although R1’s responsible party refused medical treatment for R1, the facility did not seek appropriate medical attention and call 9-1-1 per Title 22 regulations.

A deficiency was cited for violating California Code of Regulations, Title 22 Division 6, Chapter 8, §87465(g) Incidental Medical and Dental Care Services - The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SUN OAK ASSISTED LIVING	FACILITY NUMBER: 342700705
	VISIT DATE: 04/19/2023

NARRATIVE

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At the time of the complaint visit, on May 27, 2021, an immediate civil penalty of $1,000 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee not seeking timely medical attention for multiple days after R1 complained of pain and exhibited a change in condition due to sustaining three falls.

Today April 19, 2023, the Department is issuing a Civil Penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $1,000 was issued on May 27, 2021, the amount of the civil penalty today will be $9,000.

A copy of the LIC 421D was given to Aida Ventosa and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Aida Ventosa and signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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