347005180-9-16-2021-27-AS-LMUZ-C7CN8L-20210930101431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005180
Report Date: 09/16/2021
Date Signed: 09/16/2021 05:08:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2020 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200428145646

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:	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Sara Weininger, Executive Director/Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility failed to follow reporting requirements to CCLD and/or residents' responsible parties.
Insufficient staffing.
Facility did not address resident's ongoing wandering risk.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced on 9/16/2021 to deliver findings to a complaint that was received on 4/28/2020. LPA met with Sara Weininger, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask.

During the course of the investigation, the Department interviewed Executive Director, Assisted Living Coordinator, Resident Services Director, Regional Director, (4) caregivers and (2) nursing staff. The Department reviewed documentation including, but not limited to: resident's (R1) physician reports, pre-appraisal, care plans, hospital medical records, skilled nursing medical records, March and April staffing schedules, e-mails sent by the facility to resident representatives and to the Department, facility letter regarding first positive Covid case, Department Provider Information Notices (PINs), facility incident reports and death report, and other documentation.

The results of the investigation are as follows:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2021

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 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(1)..Allegation: Facility failed to follow reporting requirements to CCLD and/or residents' responsible parties.

Reporting to the Department/CCLD: LPA received e-mail confirmation from local public health confirming that the earliest reported case of Covid-19 by the facility is from 4/1/2020, for resident (R2), and it was the only note made for the period 3/30/2020- 4/2/2020, with the other earlier cases being reported to public health after 4/1/2020. Public health notes provided to the Department document that a positive case for resident (R2) was logged on 4/1/2020 (16:08).

Executive Director stated in an email that she spoke to the Department on either 4/1/2020 or on 4/2/2020 and call logs would be able to confirm which day; however, logs were not found to be available. LPA reviewed an email sent by the facility to the Department on 4/3/2020 (8:58 pm), which included the “Line List” sent to Public Health, referencing (5) residents who began to show signs and symptoms of Covid-19 from 3/30/2020- 4/1/2020. The “Line List” specifically notes that residents (R2-R4) displayed symptoms on 3/30/2020, resident (R5) on 3/31/2020 and resident (R6) on 4/1/2020. There are no staff cases listed on the “Line List” sent on 4/3/2020 (8:58 pm); however, the email advises “We have had (3) staff members test positive and have discussed with DPH (Department of Public Health) testing all residents and team members within the community.”

Public health records and health department representative confirmed by email that the facility outbreak case was created on 4/3/2020 and the notes were entered on Saturday, 4/4/2020 (13:43) after receiving notification from the facility on 4/3/2020 about a “possible respiratory outbreak”. Notes specifically state one patient tested positive for Covid-19 and another patient is currently in the emergency department. Public Health representative confirmed by email that their case investigator received the notification of a possible outbreak on 4/3/2020; however, it’s possible the facility reported to public health on 4/2/2020 and it wasn’t forwarded to the investigator until the following day, 4/3/2020.

Case notes entered later on 4/4/2020 (14:53) indicate that a Public Health Investigator spoke to a facility nurse who stated that three (3) to four (4) staff members were confirmed to be ill, and that the staff log received was blank. Outbreak notes entered on Monday, 4/6/2020, document “Confirmed COVID-19” and public health confirmed that their case investigator made their first note within each positive staff case (S1-S4) on 4/6/2020 that is linked to the outbreak case; however, stated that it is not an exact confirmation of when the positive cases were reported.

cont on 9099C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 15 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(2)..Additional public health records showed that notes were entered for a positive resident case on 4/4/2020 (R3), 4/5/2020 (R5), 4/7/2020 (R4) and on 4/8/2020 (R6). Public health notes entered on Thursday, 4/9/2020 (10:15), indicate that a facility staff member reported that testing for all residents and staff had been ordered to be completed that day with notes dated Friday, 4/10/2020 (11:42) confirming “40+ tested positive”. Department notes dated 4/15/2020 indicate that there were 24 residents and 25 staff that had tested positive as of that day.

Executive Director indicated that their facility Regional Director had tried to contact the Department by phone on 4/6/2020, 4/7/2020 and on 4/8/2020 regarding positive cases but received no response. LPA was provided with an email sent on 4/9/2020 by an LPA as a follow up to the phone call conducted between the LPA and the facility regarding positive cases being reported. Administrator stated that the Regional Director stated to an LPA on 4/9/2020 that due to the severity of the situation, she was not going to be able to complete and submit an LIC624 at that time. Administrator’s statement and email sent by the LPA on 4/9/2020 confirm that the case was forwarded to management who requested on 4/10/2020 that the facility submit a completed line list to the Department and communicate verbally regarding positive cases. Department records document there was daily communication with the facility starting on 4/13/2020 regarding positive Covid cases and updates and changes were being noted. The Department’s technology services division was unable to locate any possible documentation for the time period, 3/27/2020- 4/12/2020, that may have been created in the system, but not viewable, due to a system error.

Reporting to resident’s responsible person:
Multiple staff interviewed stated that residents’ responsible persons were notified by phone call and email by facility managers and nurses following the first positive case. Executive Director and Regional Director also stated that, following the first positive case, all responsible persons of every family were called and a follow-up email was sent on 4/3/2020. LPA reviewed a copy of a letter dated 4/2/2020 that was emailed by the facility to resident families on 4/3/2020 (4:15 pm), advising families of the first positive case. Letter dated 4/2/2020 states that the letter is a follow up to the phone call made the prior evening and is being sent to advise families about “a positive Covid-19 diagnosis in our community”.

Executive Director stated by email “We received the first positive results (resident) on 4/1/2020. For staff it was taking several days for test results during that time and then notified families, Public health, Licensing same day verbally.” In the same email, Executive Director attached and referenced the emails sent to families on 4/6/2020 and on 4/9/2020.

cont on 9099C(3)

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 14 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(3)..LPA reviewed the e-mail sent on 4/6/2020 from Executive Director to resident families informing of testing to be conducted the following day by department of public health, and that public health “has validated our current infection control efforts and will be conducting this testing of our community members out of an abundance of caution and in line with their practice at other senior living communities in the Sacramento area.” LPA reviewed a subsequent e-mail sent on 4/9/2020 from the Regional Director/Acting Administrator, discussing the testing to take place that day. The number of positive cases is not disclosed in either e-mail, and a subsequent email, dated 4/15/2020, from Regional Director to resident families states, in part, “As you know, we currently have had residents who have tested positively for COVID-19” and indicated that the facility’s memory care unit (Reminiscence) has not had any positive cases”.

Resident's (R1)’ representative stated to the department “I became aware of the Sacramento Sunrise COVID-19 outbreak on April 1st when I was told a Sunrise staff member came back positive and two residents had fevers and that were being monitored. That night, an abatement crew came to Sunrise and sprayed down the building with disinfectant.” Resident (R1) progress notes, dated 4/1/2020 (21:41) document that resident’s family was “verbally notified of a positive case of Covid-19 within the community”.

LPA reviewed multiple pages of electronic progress notes for every resident that a Covid test was conducted for on 4/9/2020 and observed that notes were entered from 4/11/2020 - 4/12/2020 communicating individual resident results to each resident’s representative. Electronic notes dated 4/9/2020 for resident (R1) note that testing was conducted earlier that day and resident’s representative was notified, and notes entered on 4/11/2020 document that a Covid-19 test result came back positive and resident’s (R1) family and primary care physician were notified.

Administrator stated to the Department in an email, “We communicated the extent of several positive test to families and responsible parties and let them know how we were going to continue to provide care to their loved one individually. During that time there was no regulation to communicate the exact number but families were made aware there were several residents and team members”. LPA reviewed resident electronic charting notes for resident (R7) which note that resident’s representatives (2) inquired and were told by facility staff the number of positive residents and staff on 4/10/2020 and on 4/11/2020; however, the notes do not reference the exact number of cases told to resident representatives. There was no documentation made available to the Department showing that resident representatives were made aware that on/around 4/11/2020, 24 residents had received positive results and on/around 4/15/2020, 25 staff had tested positive. LPA was informed by the Executive Director that staff member (S5) communicated with many families during the Covid pandemic; however, was not available to interview with the LPA, when requested, in May 2021.
cont on 9099C(4)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 17 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(4)...PIN 20-04 issued 3/5/2020 provides guidance that a suspected or confirmed outbreak must be reported to local public health, the Department and to persons in care authorized representative as required by Title 22 Regulation 87211(a)(2). In addition, Covid-19 Resource Guide (version 3/19/2020) states that any confirmed cases of Covid-19 MUST be reported to the local health department and to the local Adult and Senior Care Regional Office representative immediately. Additionally, PIN 20-13 issued 4/16/2020- states facilities should provide immediate notice to families of all persons in care of any positive cases.

Based on information obtained from the investigation, the Department finds the portion of the allegation “Facility failed to follow reporting requirements to CCLD” to be SUBSTANTIATED- The earliest documentation that the facility reported a positive case to the Department is from 4/3/2020; however, documentation from public health shows the facility had reported a first positive case on/ by 4/1/2020 (16:08) when public health notes were entered.

Allegation: Insufficient staffing.

Executive Director and Assisted Living Coordinator stated that staffing levels are based on resident care needs and the computer system will document when care is provided and clearly state the number of caregivers determined to be needed on a shift. Executive Director stated “On average, there are five (5) to six (6) staff per shift in Assisted Living, which includes care managers and nurses and there are two (2) care managers on NOC in Assisted Living and in Memory Care”. LPA compared staffing levels for multiple days and determined that between four (4) and six (6) care manager staff worked during the “am” and “pm” shifts, and at least two (2) care manager staff worked during the “NOC” shift. LPA noted that total daily care manager hours varied from 88 to 118.5 in March 2020 and from 116 hours on 4/1/2020 to 56 hours on 4/14/2020. Executive Director indicated that a Regional Director Nurse was present in the facility from 4/7/2020-4/15/2020, and (3) other Regional/Corporate staff were present assisting and providing extra support individually during these time periods: 4/6/2020- 4/28/2020; 4/15/2020- 4/19/2020 and from 4/16/2020-5/20/2020. Executive Director explained that since regional staff are salaried, the documented hours worked as reported on time sheets were not available as those for staff who are paid hourly, explaining the decrease in documented care manager hours.

cont on 9099C(5)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 18 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(5)..Resident’s (R1) representative stated that from 4/5/2020 through 410/2020 staffing levels were very low and breakfast was not served until around 10:00 am and a janitor staff was helping to deliver food at one point. Additionally, resident’s representative stated “Staff, including nurses, were working 12-hour shifts for a least one (1) week, maybe two (2) weeks”. Executive Director confirmed that 12-hour shifts started in Assisted Living and in Memory Care on 4/9/2020 and went for a week through 4/16/2020, and the shift went from 6 am- 6 pm. April staffing schedules for Assisted Living reflect 12-hour shifts starting on 4/10/2020 and concluding for the majority of staff on 4/16/2020. Documentation shows that on 4/10/2020 and on 4/12/2020, five (5) staff worked from 6 am- 6 pm and two (2) staff worked from 6 pm- 6 am; on 4/16/2020, four (4) staff worked from 6 am – 6 pm, two (2) staff worked from 6 pm- 6 am, and three (3) staff worked from 6 pm- 2 am. March staffing schedules for Assisted Living show 8-hour shifts were primarily worked with some shorter shifts worked as well.

Another family member of resident (R1) stated that “it was not unusual for them (facility) to be short-staffed, in general, during the Pre-Covid on the “am” shift” and “there were times they wouldn’t come in the room at all- once they were short-handed, they didn’t come into change her pajamas, as it was very time consuming”, adding that “it is written in her (R1) contract to change her as one of her ADL’s” and “dressing in the “am” was not 100% done”.

One private caregiver who provided care to resident (R1) for approximately 8 months stated that she assisted resident “with everything, whenever she needed. I helped with toileting, changing her clothes at night and when she would get agitated in her room”. The same caregiver stated that resident “wanted to walk and loves to walk at night” and “would start sundowning at 9:00 pm as she would think it is another day- she really wanted to go outside and out of her room” and would finally mellow and go to sleep around 11:30 pm- 12:30 am… and would also get up around 2-3:00 am, about once a week”. The same private caregiver stated that the facility didn’t come and change resident or toilet her when she was there, as agreed to resident’s care plan, stating “I was hired for safety for her falling and for a companion”.

A second private caregiver interviewed stated that she provided care to resident for approximately 10-11 months and resident loved to walk multiple times around the facility building and she “assisted resident with eating, in the bathroom and got her dressed in the morning, making sure she didn’t move too fast, and whatever else she wanted”, adding “sometimes Sunrise didn’t get her dressed” and “staff would walk by and say hello to the resident but wouldn’t assist because I was there”.
cont on 9099C(6)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 13 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(6)...The same caregiver stated that the facility was supposed to change resident per her care plan and when she called for assistance during the “pm” shift and in the middle of the night, “sometimes Sunrise would help and sometimes they would not”, explaining that “ (R1) would normally go to use the bathroom 5-6 times during the night” and facility staff consistently “wouldn’t help as much because (R1) had a 1:1 there with her on the “pm” shift and overnight”.

A third private caregiver who provided care to resident for approximately 8-9 months indicated that she assisted resident with walking, taking care of her when she’s walking, pushing her in the wheelchair outside or taking her to the bathroom, and changing her clothes from pajamas to regular clothes and vice versa. The same caregiver confirmed that she changed resident’s brief and “sometimes the facility also changed her” and the facility were good at attending to resident and “would give (R1) meds and bring food in her room” and did not notice a difference in the care provided by the facility prior to Covid to the care provided during Covid.

All three outside caregivers interviewed confirmed that the facility did not instruct them directly to no longer come to the facility to provide care. One caregiver stated that resident’s representative told her that the facility wouldn’t allow any outside caregiver to come back and help due to multiple positive Covid-19 cases, and another caregiver stated that resident’s representative told her not to go in the facility.

Executive Director asserted that staffing “was lean but never short- we pulled from housekeeping, and servers and dishwashers were able to help too. We pulled the whole team together and were able to staff with our own people". Regional Director also indicated that the facility had extra team members for support from corporate as well as staff available to assist within the facility, explaining that facility team members are hired as "universal caregivers", meaning they are trained to do many tasks. One staff member stated that “management was always there, day and night and corporate staff was helping out with everything- medications, ADL's, food/serving meals for more than 2 weeks, until we tested the second time”. Staff Interviews concluded that staffing levels were always sufficient and when there were multiple staff who tested positive and were out for two to three weeks, shift hours were increased from eight (8) hours to twelve (12) hours to cover morning, evening and night shifts. Regional Director stated The Dept of Public Health gave permission for the staff who tested positive to care for the residents who tested positive and the staff who tested negative to be with the residents who tested negative, explaining, there were 25 staff lost because of containment areas.
cont on 9099C(7)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 11 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(7)...One staff member stated they couldn't provide 1:1 care and supervision to resident (R1) because she wasn't the only resident with Covid who needed assistance. Another staff stated "we all know she (R1) is a fall risk and we always checked on her and would keep an eye on her. We couldn't provide 1:1 care to her because we have other residents".

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED-

Allegation: Facility did not address resident's ongoing wandering risk.

Resident moved to the facility on 2/20/2019. Pre-appraisal dated 2/19/2019 documents that resident was in good health until falling on 1/9/2019 and was still recovering from the fall where she broke both wrists and suffered a non-displaced neck fracture and was hospitalized for approximately 6 weeks. Pre-appraisal notes that resident uses a walker and wheelchair and needs a one-person assist in getting in/out of bed/wheelchair and needs assistance with dressing, bathing toileting, hygiene and with hearing aids in the morning and evening, and resident does not need special observation/night supervision due to forgetfulness/confusion/wandering. Physician’s report dated 1/31/2019 notes resident is healing from wrist and neck fractures, is hard of hearing and uses hearing aids, has muscle weakness and difficult walking, needs assistance with bathing, grooming, toileting, medications, is non-ambulatory and needs a one-person assist and does not indicate a diagnosis of Dementia or mild cognitive impairment.

Resident fell on 4/24/2019 and was admitted to the hospital for a fractured pelvis.
Resident progress notes for skilled nursing, dated 4/28/2019, note that “fall precaution was initiated and maintained” and subsequent progress notes indicate that fall precautions were Physical Therapy and Occupational Therapy notes, dated 5/24/2019, indicate that resident is a fall risk and resident would be returning to the facility on 5/27/2019.

Care plan dates 5/29/2019 and 2/10/2020 note resident (R1) is at risk for falls due to wrist and spinal fractures, needs a walker/wheelchair and physical assistance from one person due to being at risk of falling. Additionally, care plan states that the facility will provide a safe environment and staff will inform resident and resident’s caregiver about safety reminders and what to do if a fall occurs. Care plan notes resident has Dementia, impaired hearing and vision.
cont on 9099C(8)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 9 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(8)...Resident representative stated that to mitigate resident’s fall risk, resident’s family hired three additional aides to provide 24/7 care for her following her return to the facility on 5/27/2019 and since “(R1) was hard of hearing, had macular degeneration and was difficult to get to the bathroom at night”. Resident representative explained that it was also difficult for resident to push the pendant and she was impatient about wanting immediate help in the bathroom. LPA reviewed a letter dated 3/13/2020 sent from resident’s representative advising the Executive Director of four (4) outside care providers that will be assisting resident.
Another family member of resident stated that after the lock-down began, the facility agreed to continue to allow resident (R1) to have a private caregiver since it was allowed before Covid and when the outside care agency said they were not sending any staff in, resident’s family members started going in to provide private care.

Updated care plan and resident progress notes, dated 3/27/2020, state that resident is at moderate risk and is required to eat all meals in the dining room for safety during the community’s Covid-19 isolation because of being a high fall risk and resident has her companion with her for safety- if not for he companion, resident would be a high risk. Additionally, care plan dated 3/27/2020 notes that resident needs walker/wheelchair and physical assist of one person for mobility along with reminders to use a pendant to call for assistance before trying to walk due to being a fall risk.

Asst Living Coordinator stated that during Pre-Covid, resident’s (R1) 1:1 caregiver was there "to be there with her and give her 1:1 so she wouldn't have a fall" and would also assist her with anything she needed, including walking with her around the community and that resident’s family would visit during the day and the 1:1 was primarily for evening and overnight. Assistant Living Coordinator stated that during Covid- the 1:1 duties changed and when the facility went on look-down resident’s 1:1 could not be in the common area after the front doors closed to visitation, and she had to stay with resident in her room".

One caregiver stated that resident “(R1) probably wandered before Covid but she had a 1:1 caregiver. During Covid time, R1 went into a resident's room because she didn't have a 1:1 companion”. Assisted Living Coordinator stated that resident had a caregiver 24/7 to assist her due to wandering and that resident wandered a few times on her own when the caregiver was sleeping.

Executive Director stated “When resident (R1) had a 1:1, she came out of her apartment on (2) occasions, at night just to see how everything was in her hall. When she didn't have a 1:1, she was wandering, she was lonely and confused.
Cont on 909C(9)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 10 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(9) point the family told me that resident’s 1:1 companion had dropped off and stopped coming in. I don't know when we were made aware, stating that the Regional Director told me on a Saturday that resident’s 1:1 caregiver was not coming in” and she reached out to the Department for assistance with staffing resources since there were no outside caregivers wiling to come to the community once the outbreak began.

LPA reviewed an email dated Sunday, 4/19/2020 (6:05 pm) from LPA Lusby providing contact information to Regional Director for two (2) outside staffing agencies who would provide care to Covid positive residents. LPA reviewed Regional Director’s response via email on 4/19/2020 (6:38 pm) that resident’s family was able to “secure private care starting tonight at 9:00 pm”. LPA Lusby, who was handling communication with Covid positive facilities at the time, stated she was initially informed, on 4/19/2020, about resident having a 1:1 and several recent falls when the Regional Director called her.

Regional Director stated “We wanted to "minimize the number of private caregivers and family coming in- we landed on allowing one family member for resident and one caregiver per day to come into the community after the pandemic starts” adding “we didn't want to pull resident’s 1:1 caregiver because she had a fall previously".

Resident representative stated that on April 5, 2020 (10 pm) one outside care agency pulled their private care giver and the facility told him that no one would provide care in a positive Covid facility and wanted to send resident to a skilled nursing facility. Resident representative explained that from April 5, (10 pm) through Friday, April 10, 2020, he and another family member filled in around-the-clock care for resident with one weekend caregiver also assisting. On Friday night, April 10, 2020 resident received a positive COVID diagnosis, which ended family and private care visits. Resident representative stated this was his decision to stop 1:1 and pull resident’s private caregiver and he immediately informed the facility managers, nurses and care providers that resident “was alone and was unsteady and a fall risk and might get up and wander at night”, indicating that the facility assured him that staff would check on resident every half hour.

Resident representative clarified that the facility told him resident’s 1:1 coverage could continue with him and other family members, if they watched a 30 minute PPE Video, but resident representative stated that resident’s family stopped providing care due to the dangers of contracting Covid and was told by the facility that there were not any outside care agencies that would send staff to a Covid positive facility. Resident’s family found an agency a week later who would send a private caregiver out, but resident had already fallen a couple of times.
cont on 9099C(10)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 12 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(10)...Resident’s family was informed that resident wandered into another resident’s room and lay down with that resident, and both residents fell to the floor. Resident charting notes and LIC624 submitted to the department document that resident was found on the floor in another resident’s room on 4/13/2020 at approximately 6:30 am and was sent out at 12:15 pm by visiting physician for hypoxia, or low oxygen, returning later that day. Hospital Emergency Room documents confirm resident arrived on 4/13/2020 at 12:29 pm and was discharged at 6:10 pm with a diagnosis of pneumonia of lower left lobe. Hospital documentation from 4/16/2020 show that resident arrived at the Emergency Department at 12:19 pm due to low oxygen saturation levels and was prescribed antibiotics and returned the same day to the facility.

Resident charting notes indicate that resident fell twice on 4/17/2020, at 8:15 am on the floor in her bathroom, and again, at 7:42 pm, on the floor by her bed. There was no hospital documentation found following either fall on 4/17/2020.

Resident charting notes note that resident fell on 4/18/2020 at 7:49 pm and was found lying on the floor next to her bed. Resident had two subsequent unobserved falls on 4/19/2020- at 8:30 am resident was found on the floor between her bed and table and at 11:30 am, resident was found on the floor in her room, shortly after returning from the ER. Resident was sent out for emergency services following the first fall on 4/19/2020 and returned in the evening on 4/19/2020, to begin hospice services. Hospital medical documentation, dated 4/19/2020, shows resident arrived for emergency medical care at 8:18 am and was discharged that day at 11:15 am with a diagnosis of a fall and back pain. The department was not able to locate a LIC624 for fall incident(s) occurring on 4/19/2020, but it was sent in.

Resident representative stated that Sunrise management said it was the family’s responsibility for the falls and the family needed to provide care for resident. Resident’s representative stated that the family offered several suggestions to address resident’s wandering once there was no longer a 1:1 caregiver available, as the facility “did not communicate they had implemented any material actions to address the risk”. Specifically, resident’s family suggested the use of a door alarm, a nanny-camera, a bed rail and offered to pay an off-duty care provider or hire more staff to watch resident. Resident’s family stated that the facility would not agree to any of these options to address resident’s wandering and the only action taken was to “pile pillows on the side of (R1’s) bed to act as a railing to keep (R1) from leaving her bed”. Interview with one caregiver revealed that they would place “two pillows between under the sheet and mattress to help (R1) from not falling” stating “she already fell twice in the last few days and was put on hospice and I didn’t want a possible third fall to cause her to die”. Another caregiver stated that resident did not have a 1:1 caregiver for “maybe 5-6 days or a week” and “we all know (R1) is a fall risk and we always checked on her and would keep an eye on her- we couldn’t provide 1:1 care to (R1) because we have other residents”.
cont on 9099C(11)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 16 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(11)...Regional Director stated she had a conversation with resident’s family about a nanny camera not being an option if the resident isn’t able to consent, and stated an alarm on the door would be too loud for other residents and did not recall the family mentioning a bed alarm. Regional Director stated that resident’s safety was discussed, and the family did not want resident to go to a skilled nursing facility. Executive Director stated that she doesn’t remember the family offering any options as she was out of the facility herself but stated “a bed rail would have been extremely unsafe- (R1) would have tried to crawl through it- it would have been very unsafe. I would have (R1) use a fall mat”. Assisted Living Coordinator stated she did not recall having a conversation with the family about any options to address resident’s wandering and the last conversation she had with the family was regarding resident testing positive for Covid-19. Resident’s family found care workers, a week later, to resume resident’s 1:1 care from 4/20/2020-4/22/2020 by agency and family members. Resident passed on 4/22/2020 at the facility.

The facility did not ensure that resident’s (R1) needs were met and resident had a 1:1 caregiver with her at all times to address resident’s fall risk and wandering/sundowning behaviors, which posed an immediate risk to resident in care. Resident wandered and had multiple falls from 4/13/2020- 4/17/2020 due to not having a 1:1 caregiver at her side at all times.

Based on information obtained, the Department finds the allegation "Facility did not address resident's ongoing wandering risk" to be Substantiated.

Based on information obtained, the Department finds the (3) allegations (3) to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) deficiencies are cited. (9099D pages).

Exit interview. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 7 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 10/15/2021 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	§ 87211. Reporting Requirements (a)(2)- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to retrain reporting staff in regards to the regulation to ensure they feel knowledgeable and comfortable about reporting to DDS. Agenda/attendees to be faxed to DSS by 10/15/2021.
	8 9 10 11 12 13 14	Based on documentation reviewed, the Licensee did not ensure that the first positive Covid case was reported within 24 hours to the Department, (reported on 4/3/2020) as it was reported to local public health on 4/1/2020, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Request Denied Type A 09/17/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirment is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to discuss other options with family members if the facility does not feel they can meet resident's care needs. Staff training to be scheduled- agenda/attendees to be faxed to the DDS by 10/15/2021.
	8 9 10 11 12 13 14	Based on interviews and documentation reviewed, the Licensee did not ensure that resident (R1), who had a diagnosis of Dementia, wandered and was a fall risk, had a 1:1 care provider to assist her from 4/11/2020 through 4/19/2020, which posed an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14

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: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 8 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 10/15/2021 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to discuss other options with family members if the facility does not feel they can meet resident's care needs. Staff training to be scheduled- agenda/attendees to be faxed to the DDS by 10/15/2021.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) had a 1:1 caregiver with her at all times from 4/11/2020- 4/19/2020, resulting in resident wandering and falling multiple times, which posed an immediate health and safety risk to resident in care. Resident's private 1:1 caregiver(s) last worked on 4/10/2020 due to Covid.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
ILS	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: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 18

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2020 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200428145646

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:	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Sara Weininger, Executive Director/Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility failed to follow universal precautions.
Resident sustained a fall resulting in a serious injury due to staff neglect.

INVESTIGATION FINDINGS:

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During the course of the investigation, the Department interviewed Executive Director, Assisted Living Coordinator, Resident Services Director, Regional Director, (4) caregivers and (2) nursing staff. The Department reviewed documentation including, but not limited to: resident's (R1) physician reports, pre-appraisal, care plans, hospital medical records, skilled nursing medical records, March and April staffing schedules, e-mails sent by the facility to resident representatives and to the Department, facility letter regarding first positive Covid case, Department Provider Information Notices (PINs), facility incident reports and death report, and other documentation.

The results of the investigation are as follows:

Allegation: Facility failed to follow universal precautions.

Interviews and documentation reviewed shows that terminal cleaning was done on 4/1/2020 after the first positive case occurred. Multiple caregivers interviewed stated that the facility took proper Covid-19 precautionary measures that included setting up a quarantine zone to separate residents who tested positive from residents who tested negative, providing PPE and sanitizers to staff and limiting/screening visitors with one staff stating, “We started a quarantine/containment zone the same night when the first 2 people got it. We would screen everybody and told staff

cont on 9099C(1)..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(1)...to stay home if they had a cough, or if a resident had any fever or change in condition such as not eating, we were notifying the family”. Another care giver stated, “We didn't bring the med carts to the Covid positive area. The nurses had carry-ons they would bring on to the positive area”. A third caregiver stated “Some of the caregivers who tested negative were serving residents who tested negative and the caregivers who tested positive were serving residents who tested positive.”

One facility nurse commented, “We started implementing measures before everyone was tested,” explaining “Outside of each resident's room who tested positive, in the containment zone, was a plastic two-flap zipper barrier to that resident's door. Staff would put on and take off their PPE in that area between the plastic door and the door to the resident's room”. Another facility nurse who tested positive on/around 3/30/2020 returned to the facility on/around 4/17/2020 stated “certain hallways were quarantined, and there was plastic walling up. Most of the positive residents were in that section,” adding “all residents were quarantined to their rooms, with meals being served in their rooms also”.

Assistant Living Coordinator stated that, in addition to setting up a quarantine wall that was zippered, staff wore full PPE and the positive residents were moved upstairs, adding “ We looked at our staffing levels and assigned the appropriate staff working with the appropriate residents” explaining “there was a two week window where we changed our staffing model. We had 3 shifts normally but changed to two 12-hour shifts from 6 am- 6 pm and 6 pm to 6 am”.

Executive Director stated that after the initial two residents who tested positive were placed on isolation and staff was checking temperatures, two times per day, for all residents and staff. Executive Director indicated that on Sunday, 4/5/2020, one (1) or two (2) residents showed a "low grade temperature" and on Monday, 4/6/2020, "many residents had a low grade fever such as 99.9 or 100.0*F", so the facility “implemented a "no visitation" policy” and was “able to get testing done for every resident and staff on 4/9/2020”, adding “we got the results very quickly, the next day, on 4/10/2020.” Executive Director explained that the staff who tested positive went out on leave and the staff who tested negative stayed, explaining, "We started to group positive residents in one central area and negative residents on the outside of the containment", stating there was some "readjusting with residents who tested negative- they had to move to a different apartment". Executive Director that as more staff and residents became infected, “We contained a certain chunk of the hallway and made a containment wall from room 202 to room 213/214, near the elevator, which was up for another 2-3 weeks, until Friday, 5/1/2020”, due to having 25 residents and 24 staff test positive by 4/15/2020. Department documentation dated 4/13/2020 shows the facility Regional Director communicated to the Department that the facility had a “temporary containment area” built for residents who had tested positive, full PPE was being used for residents who are positive, and outside medical infectious disease personnel came out and provided recommendations to facility staff.
cont on 9099C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

NARRATIVE

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9099C(2)..Email dated 4/15/2020 from Regional Director to resident families advises families “Our team members are now wearing masks throughout the community. In addition, they are wearing full personal protective equipment (PPE), such as N95 masks, goggles, gloves and gowns, while serving any residents experiencing symptoms, regardless of test results. Residents who can tolerate a mask during direct care are now requested to wear one, as well, following recent guidance from DOH. “ Additionally, the email states “We continue thorough community cleaning in addition to our evidenced-based infection control protocols” Regional Director further states that starting in February 2021, the facility significantly expanded their infection control program based on CDC guidance to include in part, increased screening protocols, limited in-person visitation, modified dining and activities to promote social distancing, reinforced hand hygiene practices.

PIN 20-07 issued 3/13/2020 discusses implementation of multiple prevention measures facilities can take to prevent/slow the spread of Covid-19 and how to isolate a suspected or confirmed Covid-19 case and the appropriate use of PPE, including facemasks, gloves, gown and eye protection.

Based on information obtained, the Department was unable to determine that the facility did not follow current Covid-19 precautionary measures in place on/around March -April 2020 when the first positive cases/outbreak occurred and finds the allegation to be UNSUBSTANTIATED-

Allegation: Resident sustained a fall resulting in a fractured pelvis due to facilities negligence as the result of Neglect/Lack of Supervision by facility staff.

On 4/24/2019, resident sustained an unwitnessed fall in the facility lobby and was immediately evaluated by on-site LVN, who noted that resident showed no signs of injury and had normal range of motion and who stated that resident complained of pain to her buttocks, but that is normal if a client falls on his/her buttocks. Resident was placed back in the lobby chair after being assessed by the LVN.

At approximately 1430 hours, resident’s son, arrived at the facility to transport resident to the mall for an outing. Resident’s son stated he noticed his mother was not acting normal, was having trouble transferring in and out of the car and requested to go back to the facility. Resident and her son returned to the facility around 1700 hours and informed staff of resident’s strange behavior and was informed that resident had fallen earlier that day. Resident’s son then requested that resident be transferred to the Hospital for further evaluation.
cont on 9099C(3)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 18

Control Number 27-AS-20200428145646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SUNRISE ASSISTED LIVING OF SACRAMENTO	FACILITY NUMBER: 347005180
	VISIT DATE: 09/16/2021

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9099(c)(3)...Hospital records indicate that resident arrived at Urgent Care on 4/24/2019 at 6:27 pm, was admitted to the hospital on 4/24/2019 (11:51 pm) with a mechanical fall and pelvic fracture and was discharged and admitted to physical therapy at a skilled nursing facility on 4/28/2019. LIC624 submitted to the Department indicates that resident was found on the floor in the front living room area at the facility on 4/24/2019 at 1:48 pm and was observed to have no injuries but complained of pain in her buttocks. When resident continued to complain of pain, resident’s family was notified, and the family took her to urgent care but was re-routed to the hospital. Resident’s family member stated that it is believed that resident fell or slipped in the morning when trying to scoot herself from the chair to the couch in the TV room.

The investigation determined that the facility followed their policy regarding an unwitnessed fall. Resident was evaluated by an LVN and exhibited no injuries and had normal range of motion. When resident was observed to have a change of condition, the family and facility sought medical attention. Multiple residents were interviewed, and none indicated to have any concerns or issues with the level of care being provided.

Care plans and assessment on file indicated that resident was a fall risk. Prior to falling on 4/24/2019, resident's initial care plan, dated 2/20/2019, noted that resident needed a walker and/or wheelchair to assist with mobility and the physical assist of (1) person and also needed safety reminders to use her pendant when needing assistance. Care plan, dated 2/20/2019, specifically states that resident is "at risk for potential fall due to C1,C2 Cervical fracture" and staff is to "observe for any changes in gait or balance", provide resident with a safe, clutter free environment and give safety reminders to use her pendant.

Resident fell a month after moving to the facility in the spring of 2019 and was hospitalized through 4/28/2019 when she was discharged to a Post-Acute Rehabilitation Center, receiving physical therapy until 5/27/2019 when she returned to the facility. Resident's family member stated in April 2020, when resident returned to the facility,"to mitigate this risk, her family hired three additional aides to provide 24/7 care for her", as the facility was unable to provide services 24/7. On 7/14/2019, the family obtained 1:1 care for resident through an outside care agency who provided care until 4/5/2020, 5 days prior to resident being diagnosed with Covid-19. Resident passed away on 4/22/2020. The death certificate notes the cause of death to be Cerebral Atherosclerosis and Hypertension.

Based on information obtained, the Department finds the above (2) allegations to be 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. Copy of report provided to facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 18