347004346-6-16-2023-59-AS-KHOS-CSYQKX-20230620121505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004346
Report Date: 06/16/2023
Date Signed: 06/16/2023 01:07:15 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
03/28/2023 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20230328144325

FACILITY NAME:	SUNRISE ASSISTED LIVING OF CARMICHAEL		FACILITY NUMBER:	347004346
ADMINISTRATOR:	TANIA LANGLAND		FACILITY TYPE:	740
ADDRESS:	5451 FAIR OAKS BLVD		TELEPHONE:	(916) 485-4500
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	66	CENSUS:	DATE:	06/16/2023
		UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	Tania Langland		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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On 6/16/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Tania Langland to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.
The investigation found that on 3/12/23, and altercation occurred between R1 and R2 in the memory care wing. Statements found that caregivers were not presnet at the onset of the altercation but responded when residents were heard yelling at one another. When staff arrived R1 and R2 were observed to hit each other. Staff reported R2 hit R1 in the shoulder. Residents were seperated and assessed to have no known injuries at that time. Increased supervision was put in place. At the time of the event, R1 and R2's responsible parties were not notified nor was a report submitted to licensing as required. Family of R1 did not observe injuries to R1 on 3/15/23. On 3/17/23, R1 was observed to have bruising to wrists, upper arms and swelling to a finger. As no other event was witnessed for R1 to .have received those injuries and the the shoulder bruising is consistent with observations of the incident.

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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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 3

Control Number 59-AS-20230328144325

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 CARMICHAEL	FACILITY NUMBER: 347004346
	VISIT DATE: 06/16/2023

NARRATIVE

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As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Tania Langland . Copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230328144325

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 CARMICHAEL	FACILITY NUMBER: 347004346
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/16/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(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 ...	1 2 3 4 5 6 7	Licensee investigated the incident, has since done staff retraining of reporting requirements and updated residents care plans for thos involved. No further plan of correction needed at this time.
	8 9 10 11 12 13 14	(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met based on the incident involoving R1 and R2 was a threat to their welfare and was not reported as required. This posed a potential resik to residents.	8 9 10 11 12 13 14
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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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

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