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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700705
Report Date: 06/20/2023
Date Signed: 06/20/2023 02:32:43 PM


Document Has Been Signed on 06/20/2023 02:32 PM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SUN OAK ASSISTED LIVINGFACILITY NUMBER:
342700705
ADMINISTRATOR:KEY, KAYEFACILITY TYPE:
740
ADDRESS:7241 CANELO HILLS DRIVETELEPHONE:
(916) 722-2800
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:78CENSUS: 28DATE:
06/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Kaye Key, Administrator TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a recent incident report submitted to the Department. LPA met with Kaye Key, Administrator, and explained purpose of inspection. Administrator provided current census of (10) residents in Memory Care and (18) residents in the Assisted Living and confirmed there are (4) residents on hospice.

LPA and Administrator discussed the incident report (SIR) submitted for an incident occurring on 6/5/23 and on 6/9/23 between resident (R1) and staff (S1). Administrator stated she did not witness either incident but was informed about them by R1's family members and S2. LPA reviewed documentation that the facility provided immediate employee counseling and development to S1 following each incident. SIR and documentation reviewed note that S1 did not communicate with R1 prior to removing her lunch plate from her during lunch on 6/5/23 and did not allow sufficient time for resident to finish lunch before offering dessert. Documentation for the incident on 6/9/23 notes that S1 was advised that it is not permissible to "double depend" any resident and the caregiver is responsible for assisting residents to the restroom in a timely manner when needed, per their care plan.

Additional documentation reviewed shows hat S1 was dismissed on 6/15/23 for the reasons noted above as well as for being observed to talk loudly to residents, not assisting residents when needed and not providing the necessary supervision and intervening when R1 began to eat her napkin during lunch. There was a second staff (S2) present during the incident at lunch and no injuries were sustained by R1. Administrator stated that although S1 tended to talk loudly so residents could hear her, she provided excellent care to residents during the Covid pandemic.

Administrator stated the facility recently completed training on providing appropriate care to residents with Dementia and Alzheimer's Dementia and is in the process of completing staff training on food training and appropriate diapering for residents. The Long Term Care Ombudsman office was also notified of the above incidents.
There are no citations being issued during today's inspection. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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