347004346-4-21-2022-25-AS-MSEY-CDQP84-20220422110451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004346
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:35:26 PM

Substantiated

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
01/05/2022 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20220105153033

FACILITY NAME:	SUNRISE ASSISTED LIVING OF CARMICHAEL		FACILITY NUMBER:	347004346
ADMINISTRATOR:	DAVINA BARKER		FACILITY TYPE:	740
ADDRESS:	5451 FAIR OAKS BLVD		TELEPHONE:	(916) 485-4500
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	66	CENSUS: 43	DATE:	04/21/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Davina Barker		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care
Emergency exits are blocked
Facility is retaining a resident that needs a higher level of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/21/22 to deliver complaint findings. 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 department reviewed client/resident records and conducted extensive interviews.
The department finds that the allegations cited above are substantiated.

Records reviewed and interviews conducted found that R1 sustained pressure injuries while in care and that between 11/23/21 and 12/17/21, Home Health notes recorded R1 to have a Stage III pressure injury

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220105153033

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: 04/21/2022

NARRATIVE

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which continued to be treated at the facility. On 3/16/22, LPA Mknelly interviewed the Executive Director (ED). In the interview, ED acknowledged that she became aware that R1 was retained in the facility with a Stage III pressure injury. In ED’s statement, they became aware when reviewing notes while the facility nurse was absent. Reported by ED, RN was unaware that Stage III pressure injuries are a prohibited condition.
While it is documented that R1 experienced pressure injuries that pressure injuries that worsened during the time noted, LPA did not find that the worsening condition from 11/23-12/17/21 was due to a lack of care.

The investigation also found that in photographs provided to LPA from a party who was present at the facility, that on 1/6/22, 11:21 AM, 2/2/22 at 10:58 am, and 2/6/22 at 11:13 am, the exit adjacent to room 208 from Reminiscence was blocked by a loveseat. LPA conducted an interview (4/5/22) with a staff who recently quit working at the facility who stated that the use of furniture to block wandering residents from attempting to exit while staffing was low happened “all the time” and they suggested LPA conduct a weekend visit during the NOC shift as it continues. LPA interviewed other staff who had worked NOC shift or AM shifts who denied knowledge to this practice. The overnight staff who worked the shifts preceding the photographs did not respond to two LPA attempted phone interviews. Photographs and a supporting statement met the preponderance of evidence.

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. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with ED . 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: 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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220105153033

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: 04/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/25/2022 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.	1 2 3 4 5 6 7	This issue was responded to at the time it was discovered by the ED. Licensee will submit proof of inservice to RCD, RN and the wellness team clarifying prohibitted health conditions by the POC date of 4/25/22
	8 9 10 11 12 13 14	This requirement was not met as evidenced by records and statements that R1 developed Stage III pressure injury and was retained at the facility. This posed an immediate health risk to R1.	8 9 10 11 12 13 14
Type B 05/05/2022 Section Cited CCR 87307(d)(6)	1 2 3 4 5 6 7	Personal Accommodations and Services (d) (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by photographs and statements that an exit was obstructed on at least three occasions	1 2 3 4 5 6 7	Submit proof of inservice training regarding removing exit obstructions timely if observed and establish routine monitoring of overall safety hazards monitoring in the facility by the POC date of 5/5/22.
	8 9 10 11 12 13 14	This posed a potential risk to resident’s health safety and personal rights.	8 9 10 11 12 13 14

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: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC9099 (FAS) - (06/04)

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