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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001957
Report Date: 04/23/2025
Date Signed: 04/23/2025 03:40:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250418122601
FACILITY NAME:SUNRISE ASSISTED LIVING OF FAIR OAKSFACILITY NUMBER:
347001957
ADMINISTRATOR:SPURLOCK, LAURIEFACILITY TYPE:
740
ADDRESS:4820 HAZEL AVETELEPHONE:
(916) 863-1499
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:74CENSUS: 55DATE:
04/23/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lydia Gravelyn, Executive DirectorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff mismanage medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Lydia Gravelyn, to deliver investigation findings into the complaint allegation listed above.

During the course of the investigation, LPA conducted interviews, conducted a medication count, and review documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Staff mismanage medication.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 59-AS-20250418122601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING OF FAIR OAKS
FACILITY NUMBER: 347001957
VISIT DATE: 04/23/2025
NARRATIVE
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During visit conducted on April 22, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing the residents’ Centrally Stored Medication Forms (CSM) with medications centrally stored for the residents. LPA observed one (1) medication for R1 to be over the amount documented in R1's CSM. Facility was unable to provide any documentation to explain why R1's medication was over the amount documented. LPA observed Medication Administration Record (MAR) for R1, which indicated that medication was administered every day since start date documented and no tabs were missed. LPA observed one (1) medication for R3 to be over the amount documented in R3's CSM. Facility was unable to provide any documentation to explain why R3's medication was over the amount documented. LPA observed MAR for R3, which indicated that medication was administered every day since start date documented and no tabs were missed. LPA observed CSMs for R3's medication dating back to November 2024 and observed that R3's medication had gaps of several days between each refill. Facility was unable to provide documentation to explain the gaps of several days in which R3 was not provided medication between each refill.

Based on a medication count, observation, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $250 is assessed for April 23, 2025 for a repeat violation within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20250418122601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING OF FAIR OAKS
FACILITY NUMBER: 347001957
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility will complete an inservice with staff regarding medication administration. Facility will also continue weekly medication audits. Facility will submit to LPA information regarding in-service training and medication audit, including time and date of in-service and training material, by POC due date.
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Based on medication count and records reviewed, the facility did not ensure that residents R1 and R3 received medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.
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A civil penalty of $250 is assessed for a repeated violation.
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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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250418122601

FACILITY NAME:SUNRISE ASSISTED LIVING OF FAIR OAKSFACILITY NUMBER:
347001957
ADMINISTRATOR:SPURLOCK, LAURIEFACILITY TYPE:
740
ADDRESS:4820 HAZEL AVETELEPHONE:
(916) 863-1499
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:74CENSUS: 55DATE:
04/23/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lydia Gravelyn, Executive DirectorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Facility has foul odor.

Staff does not ensure facility is clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Lydia Gravelyn, to deliver investigation findings into the complaint allegations listed above.

During the course of the investigation, LPA conducted interviews and toured the facility.

The results of the investigation are as follows:

Allegation: Facility has foul odor.

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20250418122601
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING OF FAIR OAKS
FACILITY NUMBER: 347001957
VISIT DATE: 04/23/2025
NARRATIVE
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Interviews with staff members S1, S2, S3, and residents R4, R5, R6, and R7 indicated that they have never observed the facility to be malodorous. Interview with ED indicated that, since starting at the facility, they have never observed the facility to be malodorous. During visits conducted on April 22, 2025 and April 23, 2025, LPA toured the premises, including the Memory Care Unit (MCU), and did not observe facility to be malodorous.

Allegation: Staff does not ensure facility is clean.

Interviews with S1, S2, S3, R4, R5, R6, and R7 indicated that they have never observed the facility to be unclean. Interviews with S1, S2, and S3 indicated that the facility does a good job with providing incontinence care to residents and ensuring facility is clean in case of an accident. Interview with ED indicated that, since starting at the facility, they have never observed the facility to be unclean. During visits conducted on April 22, 2025 and April 23, 2025, LPA toured the premises, including the MCU, and did not observe facility to be unclean.

Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5