347005180-7-22-2021-27-AS-LKIG-C582LS-20210723172958

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005180
Report Date: 07/21/2021
Date Signed: 07/22/2021 07:13:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2021 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210421145516

FACILITY NAME:	SUNRISE ASSISTED LIVING OF SACRAMENTO		FACILITY NUMBER:	347005180
ADMINISTRATOR:	SARA WEININGER		FACILITY TYPE:	740
ADDRESS:	345 MUNROE ST		TELEPHONE:	(916) 486-0200
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	70	CENSUS: 54	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Sara Weininger, Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident fell multiple times while in care due to a lack of supervision or neglect.

Resident lost an excessive amount of weight while in care due to abuse or neglect.

Resident was denied video calls.

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs conducted an unannounced visit at the care facility to complete this complaint investigation and deliver findings regarding the allegations listed above. LPA met with Executive Director/Administrator Sara Weininger and disclosed the purpose of the visit.

The investigation consisted of site inspections, reviews of the facility and medical records and interviews with facility staff and management. LPA contacted and interviewed other witnesses and obtained and reviewed copies of the resident's file and medical records. The investigation determined that the resident (R-1) had a number of falls during his residence at the care home from February 28, 2020 to October 2020. On two of the falls, the resident may have had injuries and was sent to the hospital for evaluation. On both of these serious falls, the facility submitted special incident reports to the Department and the responsible party and the resident's primary care physician were notified. Several of the falls were witnessed and in several other cases the resident was found on the floor. The resident was in the dementia unit and had lost the ability to communicate and there was no explanation of how he got to the floor for several of the incidents.

Continued:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210421145516

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 07/21/2021

NARRATIVE

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Regarding the falls, the facility informed the Primary Care Physician, had the resident reassessed and took additional fall prevention measures documented in his care plan and file. The facility received an order for a high/low hospital bed, obtained fall mats, requested and received an order for a gait belt and wheelchair, rearranged the common area, employed a one to one care giver for a period of time and obtained a referral to a neurologist. The resident was moved out of the facility by his family prior to the neurologist appointment. While the resident did have several falls at the facility, the facility took multiple steps to reassess the resident and address the falls.

Regarding the allegation that the resident lost weight at the facility due to abuse/neglect: The LPA reviewed the residents file and obtained copies of pertinent documents. The resident's Physician’s Report (LIC 602) from 2/17/20 show the resident's weight at 161. Weight on 3/16/20 was 155, 4/29/21 was 155, 7/22/20 was 143 and weight was 149 on 10/21/20 when the resident left the facility. The facility staff did observe the resident's health condition and loss of weight. The resident was reported to be very active, have difficulty chewing and swallowing and a decreased appetite. The facility provided staff to assist the resident at meal times and also contacted the resident's physician and received an order for a fortified diet which helped to stabilize then increase his weight. Interviews and records document the efforts of the facility to help with the resident's nutrition as the resident's physical and mental condition was reported to be declining rapidly. .

Regarding the allegation that the facility denied the resident video calls, the investigation determined the following information: The facility did allow and help facilitate video calls and window visits between residents and their family members. There was no evidence that the facility ever denied the video calls. There were times when the electronic devices were not available as the devices were being used with other residents, that was determined not to be intentional denial. As facility lock downs and restrictions on in person visitation were imposed, the facility initially had three iPad tablets and that number was increased to 6 as the facility was able to obtain more devices. Documentation of the video visits was obtained

Interviews and records document the efforts of the facility to help with the resident's nutrition and also to enhance their fall prevention actions. While there were specific times that the facility was not able to facilitate video visits, there was no evidence the facility ever specifically denied the visits. Statements obtained from other sources provided information that was contrary to the medical records and information obtained from the facility. For those reasons, these allegations are determined to be unsubstantiated. An unsubstantiated finding may mean that while the allegation may be true, there was not insufficient evidence to prove the allegation to be true.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

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