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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001957
Report Date: 10/16/2024
Date Signed: 10/16/2024 11:52:40 AM


Document Has Been Signed on 10/16/2024 11:52 AM - 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 ASSISTED LIVING OF FAIR OAKSFACILITY NUMBER:
347001957
ADMINISTRATOR:MOORE, JONATHONFACILITY TYPE:
740
ADDRESS:4820 HAZEL AVETELEPHONE:
(916) 863-1499
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:74CENSUS: 55DATE:
10/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cortez Jordan, Senior Executive DirectorTIME COMPLETED:
12:05 PM
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Senior Executive Director (SED), Cortez Jordan, to issue a citation in relation to a separate inspection.

During inspection conducted on 10/16/2024, it was observed that resident (R1) sustained multiple falls at the facility. Two of the falls resulted in injury according to Post Fall Evaluations provided. LPAs requested Unusual Incident Reports (SIRs) for R1's falls. Facility could not produce and supply LPAs with requested SIRs during visit.

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

Exit interview was conducted with SED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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 10/16/2024 11:52 AM - It Cannot Be Edited

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 ASSISTED LIVING OF FAIR OAKS
FACILITY NUMBER: 347001957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (...) This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 87211. Facility will submit statement to LPA by POC due date of 10/31/24.
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Based on interviews conducted and records reviewed, the facility did not ensure to report multiple falls for R1 to the licensing agency, which poses a potential health, safety, and personal rights risk to the 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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