347004346-10-1-2020-27-AS-MSEY-BU6MKL-20201007094051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004346
Report Date: 10/01/2020
Date Signed: 10/01/2020 11:24:19 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2020 and conducted by Evaluator Kevin Mknelly

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200206095901

FACILITY NAME:	SUNRISE ASSISTED LIVING OF CARMICHAEL		FACILITY NUMBER:	347004346
ADMINISTRATOR:	MUSTAFA ALI MAGHOUB		FACILITY TYPE:	740
ADDRESS:	5451 FAIR OAKS BLVD		TELEPHONE:	(916) 485-4500
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	66	CENSUS: 50	DATE:	10/01/2020
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Joe Dunham		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Lack of supervision resulting in resident falling from facility window.

INVESTIGATION FINDINGS:

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On 10/1/20, at approximately 10:15 AM,Licensing Program Analyst (LPA) Kevin Mknelly arrived and met with Joe Dunham, Administrator of facility Sunrise Assisted Living of Carmichael – 347004346 to deliver investigation findings.

On 2/11/20, the Department initiated a complaint investigation into the following allegations: Lack of supervision resulting in resident falling from their bedroom window.

During the investigation the department interviewed five facility employees, three first responders, area hospital attending physician, family member and two alarm system experts. The resident (R1), who is the subject of this investigation, was unable to participate in an interview. The investigator also collected and reviewed resident (R1) records from the facility, staff records, fire department log, medical records, photos taken by the investigator, and facility alarm logs.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

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 27-AS-20200206095901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347004346
	VISIT DATE: 10/01/2020

NARRATIVE

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The inspector conducted an inspection of R1’s bedroom.
The investigation found that on 1/21/2020, at 6:48 PM, R1 was able to open their bedroom window and remove the window screen. The window screen was removed at 6:48 PM per the alarm system that monitors the facility doors and windows. In a staff interview, conducted on 2/5/20, with S4, S4 stated they had responded to the alarm at that time and found the resident room open, the window was closed, and the resident was not present. No further action was taken by facility staff present until 8:00 PM.

Sometime between 6:48 PM and 8:00 PM hours, R1 fell from their bedroom window from the second story, resulting in a fall that caused serious bodily injuries. Medical records for R1, obtained by the investigator on 2/5/20, found injuries resulting from the fall are: Minimally displaced Zone II fracture of the sacrum. Dislocation of tarsometatarsal joint of right foot. Displaced oblique fracture of shaft of right femur. Traumatic rupture of symphysis pubis, and Fracture/Dislocation right midfoot.

In interview with S3 on 2/5/20, S3 stated that at approximately 8:00 PM, on 1/21/20, S3 went to R1’s room to check on them when S3 noticed R1wasn't in the common area “like he usually is”. R1’s room door was blocked by furniture from the inside. S3 was assisted by two other staff to gain entry. Staff found the resident room window open. The screen was missing. R1 was observed by staff to be outside on the ground, two stories below their room. 9-1-1 emergency services were activated.

On 1/27/20, the Department investigator, in the presence of the facility Administrator, Joseh Dunham, observed a silver colored screw in the left side of the window jam in R1’s bedroom window through which they had fallen in 1/21/20. This screw was bent upwards indicating the window had been forced up into the open position.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20200206095901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347004346
	VISIT DATE: 10/01/2020

NARRATIVE

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The Administrator reported to the investigator that the windows now have new screws in each window jam. According to the Administrator, these screws were added sometime after the accident. The new screws are a little larger in diameter than the previous ones and require a special screwdriver to remove.

The Department received the following records regarding R1 from the facility on 1/27/20:
LIC 602 for exam dated 5/24/19. The physician’s report states that R1 has a diagnosis of Dementia, with episodes of confusion.
R1’s Service Plan as written by the facility (date created was not visible on the copy provided). The plan states, in the category of Safety, that the Safety and Behavioral Expressions Plan contains the following:…
· (R1 has) “left the community once and have tried several other times. Please remain proactive in my activity programming …At times I feel like an outsider and may become scared and anxious if I feel no one is paying attention to me. Please provide me opportunities for success, for enjoyment, and to prevent behavioral challenges and attempts at elopement.
· My triggers for wandering/elopement were due to a recent move to a new community and my transition. Observe my location in the community, direct me to an activity , sit with me, hold my hand to comfort me and/or find out what I want to do.”

On 2/5/20, Department investigator interviewed S4. S4 stated that they received and responded to the Scout phone alert at 6:48 PM and went to the room and saw the door open and the window closed. S3 said she last saw R1 at 6:30 PM in the common area drinking coffee with another resident and there was another care giver in the same area. When asked by the investigator where R1 was when S4 checked his room at 6:48 PM, S4 stated that she didn't know, but she did see him earlier at 6:30 PM in the common area.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20200206095901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347004346
	VISIT DATE: 10/01/2020

NARRATIVE

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Based on observation, Interviews and record review, the licensee did not (CCR 87466 Observation of the Resident) ensure that R1, on 1/21/20, was regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs, for R1. R1, who was a known risk to leave the facility unaccompanied, was not observed by staff between 6:30 PM and 8: PM, even after a window alarm sounded at 6:48 PM.
This posed an immediate Health, Safety or Personal Rights risk to residents in care.

Based on observation and Interviews, the licensee did not (CCR 87307 (d)(2) Personal Accommodations and Services) ensure that the following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. The screws installed by the facility to attempt to prohibit full opening of a window were insufficient. R1 forced the window open and exited the second-floor window, sustaining serious bodily injury. This posed an immediate Health, Safety or Personal Rights risk to residents in care.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations, Division 6. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk to clients/residents in care.

During today’s facility inspection on 10/1/20, at 10:50 AM, an immediate civil penalty was issued of $500 was issued to the facility.

The facility has been advised by LPA Mknelly that under H&S Code §1569.49 the issuance of a Civil Penalty is currently under review and may be assessed at a later date, due to the resident sustaining serious bodily injury while in care of the facility.

Exit interview with administrator.
Appeals rights printed.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 27-AS-20200206095901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347004346
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 10/02/2020 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance	1 2 3 4 5 6 7	Licensee will provide proof of training completed regarding alarm responses, particularly identification of resident safety when alarms sound. POC to be submitted by 10/2/20.
	8 9 10 11 12 13 14	is provided when such observation reveals unmet needs. This requirement was not met based in observations, interviews and records review. This posed an immediate Health and Safety risk to residents in care.	8 9 10 11 12 13 14
Request Denied Type A 10/02/2020 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities: (2)The premises …shall provide a safe and healthful environment.	1 2 3 4 5 6 7	Shortly after this incident Licensee initiated installig heavier duty window stops and screeen alarms were tested.
	8 9 10 11 12 13 14	This requirement was not met based on observation and interviews. This posed an immediate Health, Safety or Personal Rights risk to residents in care.	8 9 10 11 12 13 14	Licensee will provide a summary of possible long term measures for securing second floor windows in the facility that meet building and fire regulations to CCL by 10/9/20.

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	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

LIC9099 (FAS) - (06/04)

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