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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004346
Report Date: 12/20/2023
Date Signed: 12/20/2023 01:54:28 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
08/30/2023 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230830171650
FACILITY NAME:SUNRISE ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347004346
ADMINISTRATOR:TANIA LANGLANDFACILITY TYPE:
740
ADDRESS:5451 FAIR OAKS BLVDTELEPHONE:
(916) 485-4500
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:66CENSUS: 50DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Barbara Barron, Senior Executive DirectorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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-Staff did not give resident's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/20/23, and met with Barbara Barron, Senior Executive Director, to deliver complaint investigation findings into the allegation that staff did not give resident's medication as prescribed.

During the course of the investigation, LPA conducted 2 medication counts and obtained documentation pertinent to the investigation.

Allegation: Staff did not give resident's medication as prescribed
During a visit conducted on 10/25/23, LPA conducted a medication count for residents (R1, R2, & R3), comparing the residents' medication lists on file with medication centrally stored for the residents. LPA observed two (2) medications for R1 that were off count in relation to what was documented. One medication was over the amount documented and the other was under the documented amount.
********************************************Continued on LIC9099-C**************************************************
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
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 5
Control Number 59-AS-20230830171650
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: 12/20/2023
NARRATIVE
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LPA observed two (2) medications for R2 that were off count and were under the amount documented and one (1) medication that was over the amount documented. LPA observed that R3 had one (1) medication that was off count and over the documented amount. There were several of R1, R2, and R3's medications that were not observed during the first medication count conducted.

During a visit conducted on 12/14/23, LPA conducted a medication count for R1, R2, and R3 comparing the residents' medication lists on file with medication centrally stored for the residents. LPA observed one (1) medication for R1 that was off count in relation to what was documented and was over the amount documented. LPA observed one (1) medication for R2 that was off count and was over the documented amount. No medication refusals were provided for either medication counts conducted on 10/25/23 and 12/14/23.

According to R1's medication list, R1 is prescribed to receive Insulin before meals. Interviews conducted with staff (S3, S4, & S5) indicated that they were on duty during the brunch event the facility held on 8/27/23. S3, S4, and S5 recall that there were no nurses on duty during the morning shift on 8/27/23. The nurse scheduled (S2) came in after the brunch event. According to the schedule provided to LPA, S2 was the only nurse scheduled on 8/27/23. S2 was scheduled for the PM shift starting at 2pm. S3 indicated that R1's responsible party was concerned that R1 had not received their insulin injection prior to mealtime as prescribed. Interview with S3 indicated that they spoke with S4 regarding R1's responsible party's concern regarding the insulin medication. Interview with S4 and S5 indicated that they assisted each other with providing insulin injections using the hand-over-hand method for any residents requiring insulin injections. S4 and S5 both recall that R1's insulin medication may have been given late during the brunch event on 8/27/23.

Based on interviews conducted, a medication count, 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, a deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/30/2023 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230830171650

FACILITY NAME:SUNRISE ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347004346
ADMINISTRATOR:TANIA LANGLANDFACILITY TYPE:
740
ADDRESS:5451 FAIR OAKS BLVDTELEPHONE:
(916) 485-4500
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:66CENSUS: 50DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Barbara Barron, Senior Executive DirectorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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-Unqualified staff dispensed medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/20/23, and met with Barbara Barron, Senior Executive Director, to deliver complaint investigation findings into the allegation that unqualified staff dispensed medication.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.

Allegation: Unqualified staff dispensed medication
Interview with the Executive Director (ED), Tania Langland, indicated that the facility had hired plenty of nurses so that the facility does not have to rely on Med Techs to assist with insulin injections. ED stated that, only in emergency situations, the facility will utilize Med Techs to assist residents with insulin injections. ED stated that Med Techs are trained to do hand-over-hand when assisting with injections. ED indicated that the
**********************************************Continued on LIC9099-C*************************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20230830171650
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: 12/20/2023
NARRATIVE
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facility has a total of 5 nurses that work at the facility. ED indicated that there are only two Med Techs that have been used for insulin injections in an emergency situation.

Interviews with staff (S1 & S2) indicated that the nurses at the facility can assist residents with insulin injections. Interviews also indicated that the Med Techs who are trained to assist residents with injections use the hand-over-hand method. S1 stated that the residents understand how to do their own injections with hand-over-hand assistance from a Med Tech. S2 stated that some residents require more assistance with injections than the hand-over-hand method and a nurse would provide the assistance.

The facility provided LPA with training documentation indicating that the two staff (S4 & S5) utilized to assist with hand-over-hand injections have completed medication training. The facility also provided documentation indicating that the 5 vocational nurses have current licenses through the Board of Vocational Nursing and Psychiatric Technicians.

Based on interviews conducted and documentation reviewed, although the allegations may have
happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not
occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited during this visit.

Exit interview conducted. A copy of this report provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20230830171650
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: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
87465(a)(4)
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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:
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Facility agrees to have all med-techs and nurses sign a statement of understanding of job duties to address medication management to submit to LPA by the POC due date of 12/21/23. Faciliy will also complete bi-weekly audits of all medications for the next month and submit to LPA.

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Based on medication counts and records reviewed, the facility did not ensure that residents (R1, R2, & R3) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to 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: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5