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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001314
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:41:01 PM

Document Has Been Signed on 07/07/2023 03:41 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 RESIDENTIAL CARE SERVICES, INC. (#2)FACILITY NUMBER:
347001314
ADMINISTRATOR:DICKEY, MAYEFACILITY TYPE:
735
ADDRESS:8139 WACHTEL WAYTELEPHONE:
(916) 725-6647
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 6DATE:
07/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Encarnacion Carmen, DSP TIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to deficiencies observed and cited by Alta California Regional Center (ACRC) on/around 4/27/2023. LPA met with Encarnacion Carmen, DSP, who contacted LuzviMinda "Mindy" Cailing, DSP, by phone. LPA spoke to Mindy, and explained purpose of inspection. Mindy stated she was not able to meet LPA at the facility now and agreed to contact Maye Dickey, Administrator. LPA met with Maye Dickey, Administrator, at approximately 1:45 pm and explained purpose of inspection. Administrator confirmed (4) residents were attending day program during the inspection. LPA observed (1) client return during the inspection.

LPA reviewed the Facility Action Report/Corrective Action Plan provided to the Department by ACRC on 5/25/2023, describing the specific deficiencies found. Also provided was a letter explaining the facility had been placed on Sanctions as of 5/25/2023 due to (2) substantial deficiencies at the facility within a (12) month period. The deficiencies were observed on 4/27/2023, as follows:

Medication error was discovered for Client (C1). Specifically, the medication Xcopri 12.5mg and 25 mg packet was prescribed on 2/2/2023 but was not included on the Centrally Stored Medication Record (LIC622). Documentation reviewed dated 2/28/2023 notes the doctor was not able to send a refill request due to insurance reasons and C1 last took this medication on 3/4/2023. There was no documentation on file that C1 would be okay without taking this medication while the refill was pending. Facility was asked to schedule an appointment with C1's specialist and did later obtain a scheduled appointment in August 2023.

Medication errors were also discovered for client (C2). Specifically, an order was observed for a MultiVitamin; however, there was no medication observed to be available to administer to C2, and the medication was not listed on either the LIC622 or Medication Administration Record (MAR).
cont on 809C(1)...
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNRISE RESIDENTIAL CARE SERVICES, INC. (#2)
FACILITY NUMBER: 347001314
VISIT DATE: 07/07/2023
NARRATIVE
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809C1... Also discovered while reviewing C2's medications was the prescription for Risperidone 2 mg had no remaining refills and C2 went without the medication from 4/10/2023- 4/19/2023, as observed on the MAR. Staff notes indicate that the physician was contacted for a refill but the physician was out of the office and the facility was redirected to another physician.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) related deficiencies are being issued on the 809-D pages.

Exit interview. Copy of report and appeal rights to be emailed to Administrator immediately following the inspection.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2023 03:41 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 07/07/2023 at 01:59 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 RESIDENTIAL CARE SERVICES, INC. (#2)
FACILITY NUMBER: 347001314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement is not met as evidenced by:
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Licensee/Administrator submitted a written protocol to ACRC outlining how facility will ensure medication refills are completed timely, all medications are being administered as ordered and how to correctly complete the MAR and LIC622.

LPA to request documentation of completed POC from ACRC.
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Based on record review on 4/27/2023, the Licensee did not ensure that client (C1) received ordered medication, Xcopri 12.5 mg, from 3/5/2023 through 5/30/2023, and client (C2) received ordered medication, Risperidone 2 mg from 4/10/2023- 4/19/2023, and MultiVitamin for an extended period of time, which posed an immediate health and safety risk to clients in care.
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Type B
07/21/2023
Section Cited
CCR80061(b)(1)(E)

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80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following:(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:
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Licensee/Administrator agree to forward to the Department the completed SIR's (incident reports) sent to ACRC.

Also, Licensee/Administrator agree to read Reg 80061 with staff and submit a signed statement that it is understood. LPA will email regulation. Due by 7/21/2023.
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Based on documentation reviewed, the Licensee did not ensure that medication errors were reported to the Department within (7) days, which posed a potential 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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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