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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004346
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:33:28 PM


Document Has Been Signed on 08/30/2022 03:33 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
CHICO - RESIDENTIAL, 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: 41DATE:
08/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lyndee Whaley, Christina Bond , Rachel WestTIME COMPLETED:
04:00 PM
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On 8/30/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management regarding a serious injury incident report the Department on 8/23/2022. LPA Yang met with Executive Director, Lyndee Whaley, Terrence Club Coordinator, Rachel West and Resident Care Director, Christina Bond and explained the purpose of the visit.

Prior to initiating the 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 she 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.

On 8/19/2022, R1 was reported to have fallen when attempting to self transfer to the bathroom. R1 was found on the floor and 911 was called. R1 was reported to be in severe pain and was transported to UC Davis Medical Center. R1 was discharged from the hospital and returned to the community later that day.

LPA interviewed with (4) staff and obtained copies of the visitor log of August 19, 2022 and August 20,2022, R1's resident profile, UC Davis After Visit Summary, R1's Death Report and Home Health Visit Report.

As a result of today’s inspection, no deficiencies were noted.
LPA reviewed the report with Executive Director and a copy was provided and left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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