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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603793
Report Date: 06/22/2021
Date Signed: 06/22/2021 04:55:47 PM

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 OF SABRE SPRINGSFACILITY NUMBER:
374603793
ADMINISTRATOR:KLEMP, SHAUNA LYNNFACILITY TYPE:
740
ADDRESS:12515 SPRINGHURST DRTELEPHONE:
(858) 391-9160
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:100CENSUS: 94DATE:
06/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Director of Sales, Michelle RoselundTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management visit. LPA was greeted by staff, Kit Quiba. LPA met with Director of Sales, Michelle Roselund and discussed the purpose of the visit.

On May 14, 2021, Community Care Licensing received a self reported incident regarding Resident #1 (R1). On May 5, 2021, R1 was found by facility staff on the floor in their room and sustained an injury. R1 was last observed at the end of breakfast at approximately 10:00am. Staff went to R1's room at approximately 10:45am to administer medications and found R1 on the floor. R1 was assisted up by staff off the floor. R1 didn't complain of any pain. Then on May 7, 2021, R1 complained of pain and was transported to the hospital by non emergency ambulance. Once R1 was discharged from the hospital, R1 went to a skilled nursing facility for recovery and did not return to the facility.

During today's visit, LPA briefly toured the facility, requested records and interviewed staff. No deficiencies were issued.

An exit interview was conducted with Director of Sales, Michelle Roselund and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Director of Sales, Michelle Roselund via electronic mail. An electronic read receipt confirmation was requested to be sent by the Director of Sales, Michelle Roselund upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1]
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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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