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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004346
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:37:36 PM


Document Has Been Signed on 04/21/2022 02:37 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SUNRISE ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347004346
ADMINISTRATOR:DAVINA BARKERFACILITY TYPE:
740
ADDRESS:5451 FAIR OAKS BLVDTELEPHONE:
(916) 485-4500
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:66CENSUS: 43DATE:
04/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Davina BarkerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/21/22 for a Case Management visit. LPA met with Executive Director (ED) and explained the purpose of the visit. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.
The purpose of this inspection was to follow-up on incident reports received by the department.
On 4/1/22, R1 was reported to have fallen when attempting to self transfer in the bathroom. Resident was properly supervised and assisted with care. The fall occurred due to the resident's not following transfer assistance recommendations. On 4/14/22, R2, was found to have developed a stage II pressure injury. LPA found that necessary care and supervision was provided to R2. LPA advised a more formal documentation system for resident skin care checks be instituted and maintained when applicable for residents of concern. On 4/16/22, R2 who has a history of GI issues, developed a GI bleed. Medical care was provided timely. LPA advised that resident conditions be identified for all residents to ensure staff notify managers for changes of condition promptly.
As a result of today’s inspection, no deficiencies were noted.
LPA reviewed the report with ED and provided a copy
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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