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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701337
Report Date: 08/30/2024
Date Signed: 08/30/2024 04:32:06 PM

Document Has Been Signed on 08/30/2024 04:32 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SONRISE CAREHOME INCFACILITY NUMBER:
342701337
ADMINISTRATOR/
DIRECTOR:		GACILAN, JESSICAFACILITY TYPE:
735
ADDRESS:8195 YORKTON WAYTELEPHONE:
(916) 396-7083
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 4CENSUS: 4DATE:
08/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Jaime Gacilan TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Jaime Gacilan and stated the purpose of today’s visit.

The purpose of this case management visit is to follow up on a medication error occurred on 8/13/2024. The Department received a Special Incident Report on 8/13/2024 regarding medication error for a client. Per incident report, Alta Regional Center, Service Coordinator Gurion conducted a Title 17 and noticed that client R1’s morning medication Protonix DR 40mg was not administered due to the pharmacy’s bubble pack was not correctly pack and dated therefore resulting in a missed medication dose.

During today’s visit, LPA Truong toured the facility and interviewed staff. It was learned that R1 has been taking Protonix (Pantoprazole) 40mg , 1 tab every other day. The pharmacy put R1’s Protonix in bubble pack, but it was out of sequence. There was no Protonix in bubble pack for 8/13/24. It was learned that staff signed off R1’s MAR on 8/13/24, but the medication was not given. R1 missed 1 day of medication and resume medication the next day.

Per California Code of Regulations (CCR) – a deficiency is being cited on the attached LIC 809-D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. Exit interview held and copy of report given.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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Document Has Been Signed on 08/30/2024 04:32 PM - It Cannot Be Edited


Created By: Tung Truong On 08/30/2024 at 04:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SONRISE CAREHOME INC
FACILITY NUMBER: 342701337

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
80075(b)

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80075(b) Health Related Services.
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidenced by:
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Licensee/Administrator shall submit a plan of action and conducted in-service training to all those staff responsible for medication administration, including the staff members responsible for the medication error. Email POC to LPA by POC due date 9/13/2024.
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Based on interview and records review, the Licensee did not ensure R1's MAR was completed to reflect medication was administered. Staff signed off R1’s MAR, but the medication was not given. This poses a potential health and safety to clients in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
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