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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002828
Report Date: 10/11/2023
Date Signed: 10/11/2023 05:17:50 PM


Document Has Been Signed on 10/11/2023 05:17 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: 5DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ram Pratap, caregiver TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Ram Pratap, caregiver and explained the reason for the inspection. Also present was caregiver, Francis Iroko. LPA spoke to the Administrator, Anita, and lead caregiver, Steve, by phone who were not able to attend today's inspection,but provided assistance in locating binders/documentation for review. The facility is licensed for (5) residents currently and has a hospice waiver for (3). There is (1) resident currently on hospice. LPA observed (2) residents watching tv in the common area and (3) residents to be in their rooms.

LPA and Ram, caregiver, toured the interior and exterior of the facility including the common areas, (2) shared resident rooms, (2) private resident rooms, (2) resident bathrooms, kitchen, staff room and garage/locked laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen. Locked medications are kept in a separate cabinet nearby and locked toxins are kept in the garage. The inside temperature to be 73*F. Fire extinguisher was last serviced 5/25/23. Hot water temperature measured 116*F in the kitchen. There is a complete First Aid kit on site and sufficient paper products and PPE. All required postings are posted, including a blank Admission Agreement, Resident Personal Rights and Theft and Loss Policy.

The Administrator agreed to complete the Infection Control Plan (LIC9282). LPA reviewed the Emergency Disaster Plan that was last updated in July 2023. LPA observed (1) unlocked gate outside and covered patio seating. There are no pools or bodies of water. LPA reviewed (2) resident files and found them to be organized, current and complete. Meds were reviewed for (1) resident -orders matched meds being administered. LPA reviewed all staff files - all staff have current First Aid/CPR certification and have completed required initial or ongoing training through an approved on-line vendor. LPA requested an updated copy of LIC500, LIC308 and of the current liability insurance by 10/18/23. There are no deficiencies issued, but there is a Technical Violation being issued.
Exit interview with Administrator. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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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