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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001957
Report Date: 01/31/2024
Date Signed: 01/31/2024 12:53:43 PM

Document Has Been Signed on 01/31/2024 12:53 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 ASSISTED LIVING OF FAIR OAKSFACILITY NUMBER:
347001957
ADMINISTRATOR:WHALEY, LYNDEEFACILITY TYPE:
740
ADDRESS:4820 HAZEL AVETELEPHONE:
(916) 863-1499
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 74CENSUS: 60DATE:
01/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jonathon Moore, Executive DirectorTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 1/31/24 to conduct an annual continuation visit utilizing the inspection tool following the Required-1 Year Inspection conducted on 1/25/2024. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations.

First aid kit is maintained and ready for emergency use. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and three (3) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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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