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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004346
Report Date: 07/22/2022
Date Signed: 07/22/2022 12:25:17 PM


Document Has Been Signed on 07/22/2022 12:25 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: 39DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cynthia BazinTIME COMPLETED:
12:45 PM
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On 7/22/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual. LPA met with Cynthia Bazin, Executive Director, and explained purpose of inspection. Executive Director notified Maintenance Coordinator, Amir, who joined the inspection. Before today's inspection, LPA completed required COVID-19 testing protocols and completed daily assessment. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. The facility is licensed for (66) residents and has a hospice waiver for (15). There are (5) residents currently on hospice.

LPA, Maintenance Coordinator and Executive Director toured the interior of the facility including the Terrace Club Unit, Reminiscence Unit, laundry room, private resident rooms, shared residents room, guest restrooms, salon, kitchen, and common areas including the lobby area. In areas toured, LPA observed the facility to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. LPA observed PPE supplies to be available throughout the facility. LPA observed paper towels, foam soap and hand washing signs in restrooms. Fire extinguishers last serviced 4/21/2022. LPA observed all staff to be wearing surgical masks. LPA observed a current Administrator Certificate posted. LPA observed emergency food kits to be available in the kitchen, LPA observed 300 gallons of emergency water in stock. LPA observed residents doing activities in the activity room in the Terrace Club level and Reminiscence Unit level.

LPA requested an updated copy current liability insurance during today's inspection by 7/29/2022.

There were no deficiencies observed during today's inspection.

Exit interview. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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