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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601134
Report Date: 06/07/2023
Date Signed: 06/07/2023 03:07:15 PM


Document Has Been Signed on 06/07/2023 03:07 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SUNRISE AT LA COSTAFACILITY NUMBER:
374601134
ADMINISTRATOR:ERIKA CASTILEFACILITY TYPE:
740
ADDRESS:7020 MANZANITA STTELEPHONE:
(760) 930-0060
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:120CENSUS: 62DATE:
06/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Resident Care Director Mikhail Grant, LVNTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Resident Care Director Mikhail Grant.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/05/2023). According to the LIC624: on 06/03/2023, Resident #1 (R1), who resides in the facility’s secured memory care unit, briefly eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] R1 was quickly recovered by staff, unharmed/uninjured.

During today’s visit, LPA briefly toured the facility and performed a welfare check on R1, verifying that they were indeed unharmed/uninjured. LPA also reviewed pertinent care and business records and interviewed relevant staff.

Due to their baseline memory loss and disorientation, R1 was not able to participate as a reliable interviewee/historian. Per their LIC602’s Physician’s Report (dated 10/17/2022), R1's primary diagnosis was “Alzheimer’s Disease,” and their doctor determined that they were unable to safely leave the facility unassisted.

According to care records and corroborated by staff interviews: On the morning of 06/03/2023, R1 activated a 15-second delayed egress door within the facility’s memory care neighborhood, which allowed them to exit the building and walk to a nearby sidewalk. Staff #1 (S1) immediately heard the activated door alarm, but was slightly delayed responding to the door, because they were assisting another resident on the toilet. Staff #2 (S2) was already outside (taking their break), and soon saw R1 and escorted them back inside. R1 was only briefly unattended, and they were recovered without harm/injury. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SUNRISE AT LA COSTA
FACILITY NUMBER: 374601134
VISIT DATE: 06/07/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

During today’s visit, LPA, accompanied by facility management, activated/tested each of the delayed-egress doors and courtyard gate associated with the facility’s “Reminiscence” secured memory care unit. All doors correctly locked and unlocked, and alarmed and reset, consistent with regulation. LPA observed: a) There were three delayed egress doors which led from the Reminiscence interior to and from the Reminiscence courtyard. These three doors were entirely missing the required signs which are described in California Health and Safety Code; b) The “Stair C” and “Stair D” doors were delayed egress going in both directions (in and out). However, these two doors had signs on only one side of the door; and, c) For those delayed egress doors and courtyard gate that did have the required signs, in all instances the signs themselves were not positioned within 12 inches of either the panic bar or the door latching hardware, as required.

One (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also provided Technical Assistance regarding staffing and licensee’s absentee notification plan/policy.

An exit interview was conducted with Grant, to whom a copy of this report, the LIC811 Confidential Names List, the LIC9102-TA pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/07/2023 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: SUNRISE AT LA COSTA
FACILITY NUMBER: 374601134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
HSC
1569.699

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1569.699 Exit doors; egress-control devices of time-delay type; fences: "(a)(7)(A) A sign shall be provided on the door located above and within 12 inches of the panic bar or other door-latching hardware reading: 'KEEP PUSHING. THIS DOOR WILL OPEN IN __ SECONDS. ALARM WILL SOUND.'"
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Licensee agreed to install signs within 12 inches of the panic bar and/or door-latching hardware on each of its delayed-egress doors, which meet all the requirements of 1569.699. (For the Reminiscence Courtyard gate door, a sign is not required on the exterior side of the gate door, because it is only delayed-egress going out, not coming in). Licensee agreed to E-mail LPA photos of the signs in place on each door/gate, by the POC due date.
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This requirement was not met, as evidenced by: Based on observation, licensee did not provide signs meeting regulatory requirements on its delayed-egress doors, within an area of the facility where 20 of 62 residents (Resident #1 through Resident #20) resided, which posed a potential safety risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
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