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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004346
Report Date: 08/04/2021
Date Signed: 08/04/2021 04:06:07 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2021 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 25-AS-20210409155333
FACILITY NAME:SUNRISE ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347004346
ADMINISTRATOR:JOSEF DUNHAMFACILITY TYPE:
740
ADDRESS:5451 FAIR OAKS BLVDTELEPHONE:
(916) 485-4500
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:66CENSUS: 40DATE:
08/04/2021
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Davina Barker, Executive DirectorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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-Facility staff failed to report resident's change in condition to responsible party.
-Facility staff did not seek timely medical attention for a resident in care.
-Resident sustained an injury due to an unwitnessed fall.
-Resident was admitted to facility without responsible party's consent.
-Resident was moved to another room without responsible party's consent.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Davina Barker, to deliver findings into the above listed allegations. LPA wore an N95 mask and was screened upon entry in the care home. All staff wore masks in the care home. There are no COVID positive cases at the facility.

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


*************************************************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: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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 8
Control Number 25-AS-20210409155333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347004346
VISIT DATE: 08/04/2021
NARRATIVE
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Facility staff failed to report resident's change in condition to responsible party.
Incident reports indicate that the conservator was notified of falls that took place on 12/21/20 and 12/22/20. Progress notes for 12/21/20, 12/22/20 and 1/28/21 indicate that the conservator was notified of resident (R1’s) falls. Progress notes indicate that a meeting was held on 2/11/21 regarding a possible change in R1’s condition and that there was concern of a potential UTI. On 3/9/21, the facility was informed that the resident had a positive UTI lab result and was prescribed a new medication. According to the progress notes and interview with the Resident Care Coordinator, the conservator was contacted via email on 3/4/21, 3/9/21, 3/10/21, and 3/11/21 regarding an updated care plan after being re-evaluated by facility. The updated care plan does not specify that the resident had a positive UTI. The interviews, emails provided by facility, and progress notes revealed that the conservator was not notified of the resident’s positive UTI lab results.

Facility staff did not seek timely medical attention for a resident in care.
Progress notes indicate that a telephone conference was held with the conservator on 2/11/21 regarding a possible change in R1's condition and the concern of a potential UTI. Progress notes from 2/12/21 indicate that R1 was seen by a physician, a urinalysis (UA) was ordered, and the UA order was to be faxed to the facility. Progress notes from 2/22/21 notate communication with the conservator and that the conservator wanted to follow-up on UA testing. Facility informed conservator that they did not yet receive the UA order. Progress notes on 2/25/21 indicate that R1 had a doctor’s appointment and facility followed-up on the UA order. On 2/25/21, facility received documentation from All Inclusive Medical Services (AIMS), which specifies "UA culture if indicated". Progress notes from 2/26/21 indicate that a nurse from the facility contacted AIMS to follow-up on the UA order. Progress notes from 3/1/21 indicate that the facility received a new order for UA with culture if indicated and the conservator was notified. According to progress notes dated 3/2/21, the conservator picked up the UA sample from the facility on 3/2/21. The facility had several gaps of communication with the physician and UA clinic between 2/12/21-3/2/21 regarding the UA order.


****************************************************Continued on LIC9099-C*************************************************
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 25-AS-20210409155333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347004346
VISIT DATE: 08/04/2021
NARRATIVE
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Resident sustained an injury due to an unwitnessed fall.
On 12/21/20, R1 had an unwitnessed fall in one of the hallways of the facility and sustained a pelvic fracture. R1 has a history of fainting spells and facility staff utilize a documentation survey report to indicate when staff assist with R1's daily living needs. According to the documentation survey reports dated December 2020-April 2021, facility staff provided assistance with mobility and any transfer needs during all shifts. Facility staff also contacted emergency services in a timely manner after the fall on 12/21/20 and R1 received medical care. Although the allegation is Substantiated, no deficiencies are being cited for this allegation as the facility followed the needs and services plan and also ensured R1 received appropriate medical attention.

Resident was admitted to facility without responsible party's consent.
R1 was admitted to the facility on 6/29/20 and family member signed the admission agreement for R1's admission. R1's admission agreement is missing a signature from R1's conservator. R1's conservator signed R1's Care Plan dated 7/1/20, which was 2 days following the admission of R1 to the facility. The facility does not have any documentation indicating that the conservator provided written consent for admission of R1. Conservator documentation indicates "it is ordered that the conservator of the person is authorized to place the conservatee in a secured-perimeter residential care facility for the elderly". The conservator was not included in the admission of R1.

Resident was moved to another room without responsible party's consent.
Progress notes from 3/12/21 indicate that the facility contacted the conservator via email to inform them that the facility was to begin day programming for R1 in the Reminiscence (REM) neighborhood. Progress notes from 3/26/21 indicate that the facility staff spoke with the conservator to report that they are ready to move R1 to the REM neighborhood. The facility moved R1 to the REM neighborhood on 4/2/21. R1 has a diagnosis of Dementia and conservator of care. A 30-day written notice is required for any room changes unless the resident agrees to the room change. R1's conservator would be responsible for agreeing to any room changes for R1. The facility did not have any documentation indicating that a 30-day written notice was provided to R1's conservator regarding R1 moving to a new room on the second floor in REM.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of
Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D.
An exit interview was conducted with the Executive Director and a copy of this report. Appeal rights were provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 25-AS-20210409155333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347004346
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2021
Section Cited
CCR
87465(a)(1)
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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. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Administrator agrees to create a plan to ensure that, when a resident has a change in condition, the facility will arrange or assist in arranging appropriate medical care.

Administrator shall submit to LPA by the POC due date of 8/5/21.
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This requirement is not met as evidenced by:
Based on records reviewed, the facility did not ensure resident received timely medical care for UTI, as the initial concern was 2/11/21 and UA sample was not collected until 3/2/21, which posed an immediate health, safety, and personal rights risk to residents in care.
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Type B
08/18/2021
Section Cited
CCR
87705(b)(1)
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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes.
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Administrator agrees to submit a plan to ensure that, when a resident has a change in condition, all appropriate parties are informed. Administrator will also conduct a staff training regarding when a resident has a change in condition and provide LPA signatures of staff that received training.
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This requirement is not met as evidenced by:
Based on records reviewed and interviews, the facility did not ensure resident's conservator was informed of change in condition, which posed a potential health, safety, and personal rights risk to residents in care.
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Administrator shall submit to LPA by the POC due date of 8/18/21.
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: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 25-AS-20210409155333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347004346
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2021
Section Cited
CCR
87705(l)(4)(A)
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87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (4) The licensee shall maintain either of the following documents in the resident's record at the facility: (A) The conservator's written consent for admission for each resident who has been conserved under the Probate Code…
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Administrator agrees to create a plan to ensure that, when a resident is conserved, the facility receives written consent from the conservator prior to admission of the resident.

Administrator shall submit to LPA by the POC due date of 8/18/21.
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This requirement is not met as evidenced by:
Based on records reviewed, the facility did not ensure that the conservator provided written consent for admission of R1, which posed a potential health, safety, and personal rights risk to residents in care.
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Type B
08/18/2021
Section Cited
CCR
87468.2(a)(16)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (16) To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency.
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Administrator agrees to create a plan to ensure that, when a resident is conserved, the facility will provide a 30-day written notice if a resident is changing rooms or has conservator sign of form of consent.

Administrator shall submit to LPA by the POC due date of 8/18/21.
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This requirement is not met as evidenced by:
Based on records reviewed, the facility did not ensure that the conservator was provided a written 30-day notice for the room change of R1, which posed a potential 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: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2021 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 25-AS-20210409155333

FACILITY NAME:SUNRISE ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347004346
ADMINISTRATOR:JOSEF DUNHAMFACILITY TYPE:
740
ADDRESS:5451 FAIR OAKS BLVDTELEPHONE:
(916) 485-4500
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:66CENSUS: 40DATE:
08/04/2021
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Davina Barker, Executive DirectorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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-Facility staff failed to observe resident's change in condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Davina Barker, to deliver findings into the allegation listed above. LPA wore an N95 mask and was screened upon entry in the care home. All staff wore masks in the care home. There are no COVID positive cases at the facility.

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



********************************************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: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 25-AS-20210409155333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347004346
VISIT DATE: 08/04/2021
NARRATIVE
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Facility staff failed to observe resident's change in condition
Progress notes indicate that a telephone conference was held with the conservator on 2/11/21 regarding potential elimination of resident (R1) utilizing 1:1 companionship care from an outside resource. Progress notes for 2/11/21 indicate that there was concern with R1 having a potential change in condition that was recognized by the 1:1 companion. Progress Notes indicate that, during the phone conference on 2/11/21, there was discussion regarding the conservator being informed by the 1:1 companion that R1 was agitated in the mornings, which was not R1’s baseline. However, facility staff were not informed by the 1:1 companion of R1’s behavior. Progress notes indicate that R1 can get agitated and refuse assistance from staff frequently. The day after the telephone conference conducted on 2/11/21, R1 was seen by a physician regarding a potential UTI. According to interviews with the Executive Director and Residential Care Coordinator, R1 has a history of UTIs. There were no notations in any of R1’s progress notes indicating that facility staff had noticed a change in R1’s condition.

Based on interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited during this visit. Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2021 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 25-AS-20210409155333

FACILITY NAME:SUNRISE ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347004346
ADMINISTRATOR:JOSEF DUNHAMFACILITY TYPE:
740
ADDRESS:5451 FAIR OAKS BLVDTELEPHONE:
(916) 485-4500
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:66CENSUS: 40DATE:
08/04/2021
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Davina Barker, Executive DirectorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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-Staff are not providing adequate incontinent care to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Davina Barker, to deliver findings into the allegation listed above. LPA wore an N95 mask and was screened upon entry in the care home. All staff wore masks in the care home. There are no COVID positive cases at the facility.

Staff are not providing adequate incontinent care to resident
According to resident (R1’s) LIC602A Physician Reports dated 6/3/20 and 5/20/21, the physician indicated that R1 is able to care for own toileting needs. Documentation survey reports dated December 2020-April 2021, facility staff are providing assistance with toileting and bladder continence during all shifts. According to R1’s recent care plan dated 4/2/21, R1 is continent of bladder and facility staff will provide assistance as needed or requested to the restroom to maintain continence.

Based on records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 8