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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002740
Report Date: 05/26/2023
Date Signed: 05/26/2023 01:21:20 PM


Document Has Been Signed on 05/26/2023 01:21 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SUNRISE HOMESFACILITY NUMBER:
397002740
ADMINISTRATOR:ELIZABETH ABESAFACILITY TYPE:
740
ADDRESS:8100 S. BRIGHT ROADTELEPHONE:
(209) 234-2550
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:15CENSUS: 10DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth AbesaTIME COMPLETED:
01:30 PM
NARRATIVE
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On 5/26/23 at approximately 9:30am Licensing Program Analyst (LPA) Maja Jensen arrived unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Licensee Elizabeth Abesa and explained the purpose of today's visit. Elizabeth holds current Administrator certificate # 6010093740 good through 10/26/23.

LPA Jensen toured the grounds and interior of the facility. The grounds were observed to be maintained and all paths were clear of obstruction. Window screens were determined to be in good repair. There is outdoor furniture and shaded areas available for outdoor activities. LPA Jensen observed the interior of the facility to be sanitary and free of odor. The facility maintains adequate furnishings and lighting. Each bedroom was observed to have a dresser, night stand, lamp and chair. The thermostat was set at 68 degrees for the residents. The water temperature was measured at 110.9 degrees and is within the required range of 105-120 degrees. The bathrooms are equipped with grab bars at the toilet and in the shower. The bathrooms are equipped with paper towel dispensers for single use. The waste containers were observed to have tight fitting lids. The facility kitchen was inspected. The facility maintains 2 day supply of perishable food and 7 day supply of non-perishable food. Lunch preparation and service was observed. The lunch menu consisted of fish, scalloped potatoes, salad and juice. LPA Jensen observed fresh fruit and vegetables on hand. An adequate supply of linen is kept on site. Bedding was observed to be clean.

Medication was locked and inaccessible to residents in care. PRN medication is documented appropriately for effectiveness. Medication was observed to be pre-poured for the next two days. LPA Jensen conducted a count of 1 resident's medication and determined the count to be accurate. The facility maintains a first aid kit that was determined to be complete with scissors, tweezers, thermometer, manual and various wound dressings. The fire alarm and carbon monoxide detector were tested and determined to be in good working order. The facility maintains emergency lighting and supplies. The fire extinguisher was last serviced in February of 2023 and is in compliance. Continued on LIC 809C....
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOMES
FACILITY NUMBER: 397002740
VISIT DATE: 05/26/2023
NARRATIVE
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The Emergency Disaster Plan was reviewed and current. LPA Jensen observed signage for Resident Council, Personal Rights, Ombudsman, See Something, Say Something and infection Control.

LPA Jensen interviewed 1 staff member and 1 resident. LPA Jensen reviewed 3 of 10 resident files. 3 of 3 resident files contained outdated Needs and Service Plans. LPA Jensen reviewed 2 of 4 staff files. The staff files were determined to be in compliance.

LPA Jensen requested an updated copy the LIC 500.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22. Failure to correct deficiencies may result in the assessment of Civil Penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/26/2023 01:21 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SUNRISE HOMES
FACILITY NUMBER: 397002740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2023
Section Cited
CCR
87465(h)(5)

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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:
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Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by:
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The Licensee agrees to immediately cease pre-pouring medication and to conduct in-service training by 6/2/23 with proof of completion of training to be sent to maja.jensen@dss.ca.gov by POC due date.
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Based on LPA Jensen's observation of medication that was pre-poured for administration in to separate containers. This poses a potential risk to the residents health, safety and personal rights
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Type B
06/23/2023
Section Cited
CCR87463(c)

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Reappraisals
The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months. This requirement was not met as evidenced by:
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The Licensee agrees to update the Needs and Service Plans by POC due date and email an attestation that this has been completed to maja.jensen@dss.ca.gov.
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Based on LPA Jensen's review of resident files, 3 of 3 Needs and Service Plans were not updated within the last 12 months. This poses a potential risk to the health Safety and Personal Rights of residents ion 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
LIC809 (FAS) - (06/04)
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