347004346-6-16-2023-25-AS-KHOS-CSYQTQ-20230620122731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004346
Report Date: 06/16/2023
Date Signed: 06/16/2023 01:09:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2023 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20230217081106

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:	DATE:	06/16/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Tania Langland		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff do not assist resident with hearing aids.

INVESTIGATION FINDINGS:

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On 6/16/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Director/ Administrator,Tania Langland, to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.
Investigation found that on a unspecified date, staff were to have assisted R1 with weekly hearing aid battery replacement that was not done when it was discovered at a Dr. appointment that hearing aids were not working due to dead battery. This was substantiated by staff who were familiar with the event. Since the event, measures have been and continue to be in place to ensure that the incident is not repeated. LPA observation during several visits are that R1 is currently provided the assistance needed for their identified needs.
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. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed with Tania Langland . Copy of this report and appeal rights provided.

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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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 4

Control Number 25-AS-20230217081106

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347004346
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/16/2023 Section Cited CCR 87465(a)(3)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. ... by compliance with the following (3) When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use of these devices, and shall assist such persons with their utilization as needed.	1 2 3 4 5 6 7	Licensee has put measures in place to remedy the situation. No further plan of correction needed at this time.
	8 9 10 11 12 13 14	use of these devices, and shall assist such persons with their utilization as needed. This requirement was not met as evidenced by R1's hearing aid batteries not managed. This possed a potential risk to the resident	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2023 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20230217081106

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:	DATE:	06/16/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Tania Langland		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff did not follow resident's physician's order
Staff do not provide resident with housekeeping
Staff do not safeguard residents' personal belongings
Staff do not assist resident with showering
Staff do not provide resident with clean linen
Staff do not maintain facility free of hazards

INVESTIGATION FINDINGS:

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On 6/16/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with the Director.

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

Interviews and records did not find incidents where staff failed to follow resident's physician's order. There were statements that at time a family memeber was not satisfied with conversations with med techs about medication lists and times for reorders however this investigation did not find evidence of errors for resident medications
Records and interviews reviewed for the period of January- February 2023 did not find evidence to support housekeeping,clean linen or regular showering were not provided to residents R1-R4. Interviews with R1-R4 found those residents to be satisfied with the care they received.
Records and interviews did not find residents' personal belongings were mishandeled by staff.

Unsubstantiated

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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20230217081106

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNRISE ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347004346
	VISIT DATE: 06/16/2023

NARRATIVE

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Inspections during this investigation found the facility to be free of hazards. R1 was found to be a fall risk and has experienced falls. However, the reported falls were not attributed to staff failure to manage the residents environment to be a reason for the falls.

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4