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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002828
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:57:26 PM

Document Has Been Signed on 08/17/2023 04:57 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:SUNRISE SENIOR CAREFACILITY NUMBER:
345002828
ADMINISTRATOR:HEYDON, ANITAFACILITY TYPE:
740
ADDRESS:6729 SUGAR MAPLE WAYTELEPHONE:
(916) 745-4167
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 5CENSUS: 4DATE:
08/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Steve Heydon, caregiver/Administrator Designee TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a deficiency observed on 8/8/23. LPA met with Steve Heydon, caregiver/Administrator Designee, and explained purpose of inspection. Also present was care staff, Ram Pratap and Francis Iroko, who is in training. LPA observed (1) resident watching television in the common area and was informed (1) resident was currently in the hospital and (1) resident was out of the facility.

On 8/8/23, LPA observed (2) residents to be residing in room #1, (1) of whom (R1) is non-ambulatory and uses a walker to ambulate. The second resident (R2) is able to ambulate without a walker, but Administrator Designee indicated R2 prefers to use one at times. On 8/17/23, LPA was informed the same (2) residents reside in room #1; however, resident (R1) is currently in the hospital. LPA observed R2 to be in the room.

LPA discussed the last fire clearance issued on 9/23/22 for the newly converted room (#1), which is approved for (2) ambulatory residents only.

LPA discussed the current deficiency with Administrator, by phone. LPA stated R1 needs to move to a room approved for a non-ambulatory resident. Administrator Designee stated R4 will move to the shared room so R1 can occupy R4's current room if/when R1 returns from the hospital. R3 stated she is waiting for final approval to move to another location.

R1 moved to the facility on 8/1/23 and resided in rm #1 until 8/14/23 when resident was sent to the ER.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency are being cited on the attached 809-D page.

Exit interview was conducted with Administrator Designee. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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Document Has Been Signed on 08/17/2023 04:57 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 08/17/2023 at 04:11 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: SUNRISE SENIOR CARE
FACILITY NUMBER: 345002828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

(1) Nonambulatory persons.
This requirement is not met as evidenced by:
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Based on observation and record review, including the most recent fire safety inspection request (STD850), dated 9/23/22, the Licensee did not ensure that room #1 only housed ambulatory clients, which poses an immediate health and safety risk to residents 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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
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