347001957-9-25-2024-59-AS-KHOS-DAHKUD-20241029081234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001957
Report Date: 09/25/2024
Date Signed: 09/25/2024 11:01:46 AM

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
09/20/2024 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240920133852

FACILITY NAME:	SUNRISE ASSISTED LIVING OF FAIR OAKS		FACILITY NUMBER:	347001957
ADMINISTRATOR:	MOORE, JONATHON		FACILITY TYPE:	740
ADDRESS:	4820 HAZEL AVE		TELEPHONE:	(916) 863-1499
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	74	CENSUS: 57	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Jonathon Moore, Executive Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff mismanaged resident medication

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Executive Director (ED), Jonathon Moore, to open a complaint investigation into the allegation listed above.

During today's visit, LPAs conducted interviews and review documentation pertinent to the investigation.

Relevant party reported that resident (R1) received a medication via mailed cold box that went missing. It was reported that package was confirmed to be delivered. It was also discovered on 9/19/2024 that a staff member (S1) received the package and brought the package directly to R1 to be stored in their personal refrigerator.

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240920133852

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: 09/25/2024

NARRATIVE

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Interview with ED indicated that an injectable medication for R1 was received by the facility on 9/12/2024 and S1 brought the package in which medication was stored directly to R1 and placed contents in R1's refrigerator. ED stated that it was believed that R1 self-administered the injectable medication. Interview with S1 indicated that they received a package for R1 while working at the front desk and observed that package needed to be refrigerated immediately. S1 stated that they noticed the name on the package and took the package to R1's room right away. S1 stated that they opened the package with R1 and had R1 stored contents of package in their refrigerator.

LPAs received a Special Incident Report (SIR) regarding the incident date 9/19/2024. SIR states "Resident had medication delivered on 9/12/2024. Medication was not located in the community. On 9/19/2024 it was discovered that an employee had taken the medication directly to the resident, who then self-administered. Resident observed and monitored, determined to be ok."

LPAs reviewed R1's Physician's Report LIC 602A dated 3/18/2024, which states R1 is not able to administer own prescription medications but is able to administer own injections with assistance and observation. LIC 602A also states that R1 is not able to store own medications.

Based on interviews conducted 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, deficiencies are being cited on the attached 9099-D page.

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.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240920133852

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: 09/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/26/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Facility will complete an inservice with staff regarding medication administration. Facility will submit to LPA information regarding in-service training by POC due date.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the facility did not ensure that resident R1 received assistance with medication administration in accordance with their Physician's Report, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 09/26/2024 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will complete an inservice with staff regarding centrally storing medication. Facility will submit to LPA information regarding in-service training by POC due date.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the facility did not ensure that R1's medication was centrally stored in a safe and locked place, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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