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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002740
Report Date: 09/16/2022
Date Signed: 09/16/2022 12:47:21 PM

Document Has Been Signed on 09/16/2022 12:47 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: 12DATE:
09/16/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elizabeth AdesaTIME COMPLETED:
01:00 PM
NARRATIVE
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On 9/16/22 at 10:00am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly health and safety check. LPA Jensen met with Administrator Elizabeth Abesa and explained the purpose of today's visit. Upon arrival LPA Jensen was screened for COVID-19 and signed in at the front entrance.

LPA Jensen observed the ambient temperature in the facility to be 72 degrees which falls within the regulatory range of 68-85 degrees. LPA Jensen measured the water temperature in 1 bathroom at 129.7 degrees, there was a caution hot water sign posted above the faucet. LPA Jensen observed a 2 day supply of perishable food and a 7 day supply of non-perishable food on site. No expired food was observed at the facility. LPA Jensen observed lunch service which consisted of broccoli, rice, macaroni and cheese and fish sticks with the option of chicken nuggets for anyone that doesn't eat fish. At 11:30am LPA Jensen observed traps in the kitchen for rodents and rodent droppings on the floor of the facility kitchen in 2 places, on each side of the dividing wall that separates the kitchen and the dining room. LPA Jensen interviewed Administrator Elizabeth Abesa who advised that they have a contract with a pest control company Terminix who is on schedule to come out bi-monthly. The Administrator confirmed that because the facility is located in a rural agricultural area there are rodents and the pest control company is working with the facility to eradicate the problem.

LPA Jensen reviewed two staff files for staff 1 (S1) and staff 2 (S2). S1 had verification of completion for on-line training for CPR that was completed in 2021 but a certification of completion that includes hands on practice and evaluation was not present in the file. The resident file for S2 did not contain a CPR certificate or any evidence of CPR training. LPA Jensen interviewed the Administrator regarding the CPR certifications.

Continued on LIC 809c....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 09/16/2022
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Continued from LIC 809....

The Administrator confirmed that S2 is not CPR certified and stated that S1 had completed the certification process in 2021 but the certification was not received for placement in the file or available during the course of the visit.

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a copy of this report along with appeal rights was given to the facility Administrator Elizabeth Abesa.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2022 12:47 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/16/2022 at 12:03 PM
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 HOMES
FACILITY NUMBER: 397002740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2022
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Licensee agrees to conduct a deep clean of the combined kitchen/dining room area. Licensee will email photos or video as proof of correction to maja.jensen@dss.ca.gov by due date
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Based on LPA's observation of rodent droppings in two places in the kitchen area adjacent to the dining room. This poses a potential health, safety and personal rights risk to residents in care.
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Type B
10/14/2022
Section Cited
CCR87411(c)(1)

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(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by:



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Licensee agrees have to have all staff that provides care to residents 1st aid certified by the Plan of Correction due date. Licensee will email proof of CPR certification for S1 and S2 to maja.jensen@dss.ca.gov by due date.
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Based on LPA Jensen observation that 2 of 2 staff present during the facility visit did not have current 1st aid certifications present in their staff files. This poses a potential health, safety and personal rights 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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
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