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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004346
Report Date: 04/13/2022
Date Signed: 04/13/2022 01:13:47 PM

Unsubstantiated


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
10/05/2021 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20211005083639
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:
04/13/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Davina BarkerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff physically assaulted the resident in care.
Staff did not report properly report incident to responsible party.
INVESTIGATION FINDINGS:
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On 4/13/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with clinical staff. 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. Upon arrival, completed a facility risk assessment. 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 with temperature at the facility.

The department conducted records review and extensive interviews.
The department is unable to find and or meet the preponderance, per policy.

Report continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
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 25-AS-20211005083639
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: 04/13/2022
NARRATIVE
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The investigation found that On 09-05-2021 at approximately 0600 hours, S1 and R1 were in the restroom at the facility.
R1 allegedly became violent and started attacking S1. S1 attempted to leave the restroom, when R1 suddenly grabbed S1’s arm and pinned it behind S1’s back. According to S1, S1 repeatedly asked R1 to release them but R1 refused. S1 had to forcibly pull her hand free from R1 but in doing so, R1 lost their balance and stumbled backwards. Initially, S1 believed R1 to be okay but then S1 noticed blood on R1’s head. S1 called for help but received no response. S1 walked R1 to the Med-Tech room and asked for help. R1 was transported to an area hospital.
Per medical records from the area Emergency Room, R1 sustained a 2cm laceration to their head and was given staples as treatment. R1 was release back to the facility on the same day.
Per facility staff and R1’s medical history, R1 has a diagnosis of dementia. Records and interviews found R1 has a history of becoming confused and in her confusion, R1, at times, becomes physically and verbally aggressive towards residents or staff.

The department interviewed several staff members. All staff essentially provided the same story. R1 has been physically aggressive towards them and other residents. The staff that has worked with S1 stated she is professional and really cares for residents. No staff member interviewed has witnessed S1 become aggressive towards residents. No staff could comment on the incidents of the fall as they were not present. Staff stated they do not believe S1 pushed R1. An attempt was made to interview R1 who was unable to stay engaged in the interview. Multiple attempts were made to interview S1 however S1 had resigned and did not return calls.

The facility staff informed PoA, R1 sustained an unwitnessed fall on 9/5/21.
On the evening of 9/5/21, facility notes that staff spoke with PoA at 6:52 PM to update PoA of R1’s status. Report continued.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20211005083639
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: 04/13/2022
NARRATIVE
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Care staff reported to LPA that they recall that R1 was in a physical altercation with S1 on 9/5/21 that resulted in R1’s fall and injury. Staff could not recall the exact day and time that PoA was informed.
Facility Resident care coordinator told investigator that on 9/5/21, they informed on-floor supervisor of R1’s fall. Supervisor notified R1’s family of the fall and called an ambulance.
Community Care Licensing received an incident report on describing R1’s fall as unwitnessed.
On 3/17/22, R1’s PoA told investigator that on 9-05-2021 at approximately 0600 hours she received a call from the facility stating R1 was being sent to the hospital for an unwitnessed fall. PoA stated she does not recall who she spoke with on the phone. The staff member who called PoA stated staff turned the corner and witnessed R1 standing outside her bedroom with blood from her head. The staff member asked R1 what happened but due to R1’s dementia, R1 was unable to tell her what happened. The staff member stated she believes R1 could have fallen in her bathroom.
PoA further reported that she did not get a call from the facility’s Executive Director until 9-16-2021 to tell her what the more detailed description of S1 and R1 having a physical struggle when R1 fell and sustained an injury.
LPA Mknelly received information from facility staff who had spoken with PoA between 9/5/21 and 9/16/22 that they believe PoA knew that S1 was with R1 at the time of the fall and that there was an investigation to the incident.
However, Administrator presented LPA with a note that on 9/13/21 they had a “follow-up call” with PoA with the results of their internal investigation.


As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3