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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005180
Report Date: 03/07/2022
Date Signed: 03/07/2022 10:14:05 AM

Document Has Been Signed on 03/07/2022 10:14 AM - 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:SUNRISE ASSISTED LIVING OF SACRAMENTOFACILITY NUMBER:
347005180
ADMINISTRATOR:SARA WEININGERFACILITY TYPE:
740
ADDRESS:345 MUNROE STTELEPHONE:
(916) 486-0200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 70CENSUS: 53DATE:
03/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sara WeiningerTIME COMPLETED:
10:20 AM
NARRATIVE
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On 3/7/22 at 9:00 AM Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced case management inspection. LPA conducted a risk assessment call prior to entry verifying there were no active covid cases. LPA met with Administrator Sara Weininger and stated the purpose of this inspection.

On 2/13/22 Resident 1 (R1) AWOL'd from the facility. On R1's LIC602 it states resident is unable to leave the facility unassisted. During the NOC shift, R1 walked out of the front door, causing the alarm to go off. Staff quickly ran to the front and did not see anyone around, so they went to do room checks for all residents. Staff noticed R1 was missing and quickly alerted Sacramento PD, Fire Dept, and the family. It was brought to attention that R1's personal home is near the facility, and R1 went to get some belongings. R1's family stated to facility staff that R1 has never had a history of wandering. Prior to R1's AWOL, R1 was living in assisted living, but after this incident R1's family and Administrator agreed to move R1 to Memory Care unit.

The following deficiencies cited on the following 809D pursuant to title 22 rules and regulations, health and safety code.

Appeal rights were printed and given to Administrator and Exit Interview was conducted.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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Document Has Been Signed on 03/07/2022 10:14 AM - It Cannot Be Edited


Created By: Christopher Hopkins-Clarke On 03/07/2022 at 09:40 AM
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: SUNRISE ASSISTED LIVING OF SACRAMENTO
FACILITY NUMBER: 347005180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2022
Section Cited
HSC
1569.2(c)

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1569.2(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not as evidenced by:
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Administrator has agreed to submit a written plan to prevent this from happening again. Administrator has agreed to give written notice to LPA by POC due date 3/8/2022.
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Based on record review and interview, the licensee did not ensure Resident 1's (R1) LIC602 was being followed, and that the resident was kept safe. This poses an immediate health and safety 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:Christopher Hopkins-Clarke
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022


LIC809 (FAS) - (06/04)
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