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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004852
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:15:18 PM

Document Has Been Signed on 05/18/2022 02:15 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNRIVER SENIOR CARE, LLC.FACILITY NUMBER:
347004852
ADMINISTRATOR:DIZON, SUSIEFACILITY TYPE:
740
ADDRESS:11229 PECOS RIVER COURTTELEPHONE:
(916) 853-1925
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 6CENSUS: 5DATE:
05/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Susie DizonTIME COMPLETED:
02:45 PM
NARRATIVE
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On 5/18/22 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Managed inspection to ensure the previously cited deficiency has been corrected and staff were accurately documenting medication administration.

LPA arrived at the facility and was greeted by staff. LPA immediately reviewed the medication administration logs and observed that staff had not documented any morning medications administered to residents on 5/18/22. LPA was unable to clear the POC.

The following deficiency was cited per California Code of Regulations Title 22. Exit interview was conducted and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/18/2022 02:15 PM - It Cannot Be Edited


Created By: Kevin Gould On 05/18/2022 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRIVER SENIOR CARE, LLC.
FACILITY NUMBER: 347004852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2022
Section Cited
CCR
87465(a)(1)

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Incidental Medical and Dental Care Services: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPAs review of all resident's medication administration logs where LPA observed errors in documenting medication
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The facility will conduct additional medication administration training for all staff who administer medications from an outside source. Facility administrator will conduct daily inspections of the medication administration logs and will send weekly copies of medication administration to LPA and will report any observed errors via an incident report.
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administration logs on 5 of 5 resident logs with no documentation of morning medications administered for all five residents in care which poses an immediate health, safety and personal rights risk to residents in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
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