435202623-7-6-2023-26-AS-KHOS-CZXL9H-20240129073333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:49:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2021 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20210318093226

FACILITY NAME:	SUNRISE ASSISTED LIVING OF PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	FLAVIO SILVA		FACILITY TYPE:	740
ADDRESS:	2701 EL CAMINO REAL		TELEPHONE:	(703) 273-7500
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	97	CENSUS: 70	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Kathleen Olson		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not follow physician orders.
Staff did not meet supervision needs of residents.
Staff did not assist residents with activities of daily living.
Staff did not assist residents with basic services.
Staff did not provide meals of the quality or quantity to meet the needs of residents.
Residents were not accorded dignity.
Facility is not kept clean.

INVESTIGATION FINDINGS:

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LPA Marrufo conducted an unannounced complaint investigation visit and met with Kathleen Olson. On 03/18/2021, the Department received a complaint with the above allegations. On 03/25/2021, the Department conducted an intial complaint investigation visit and conducted further visits on 03/29/2021, 06/30/2023, and 07/06/2023.

LPA Marrufo interviewed 8 residents, including R1, 3 resident responsible parties (for 3 out of the 8 interviewed residents who were from memory care), 10 care giver staff, and 3 kitchen staff.

R1’s Physician’s Report from 11/27/2019 indicated R1 has a diagnosis of Alzheimer’s Dementia. The Physician’s Report indicates R1 is able to bathe self, dress/groom self, able to follow instructions, and able to communicate needs. The Physician’s Report indicates R1 is ambulatory. See LIC9099-C for more information. Page 1 of 8.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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 8

Control Number 26-AS-20210318093226

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 07/06/2023

NARRATIVE

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R1’s Visual/Bedside Individual Service Plan Report is dated 03/29/2021. The Dressing section states “Stockings: Compression applied – REMIND HIM to apply” and “Stockings: Compression removed – REMIND HIM to remove.”

R1’s Physician made an order to the facility for R1 to have compression stockings for both feet on 01/27/2021.

R1’s Intervention Schedule indicates that the first entry for reminding R1 to apply and remove R1’s compression stockings started on 01/27/2021. The Intervention Schedule has an “X” on the following days for the intervention of staff reminding R1 to remove the compression stocking: 01/31/2021, 02/28/2021, and 03/31/2021. The rest of the days of the month from January to March 2021 indicate that staff reminded R1 to apply and remove R1’s compression stocking.

During interview, staff S1 stated that an “X” may indicate that either staff missed the intervention, or the resident refused the intervention.

Witness 1 (W1) provided photographs to LPA Marrufo of what W1 says is R1’s ankle showing markings of the fastener from the compression stockings. R1’s ankle appears narrower where the fastener markings are visible.

LPA Marrufo reviewed R1’s resident record and did not find any document from R1's physician holding facility staff responsible for assisting R1 with the use of the compression stockings.

R1’s resident record contains a note from R1’s Primary Care Physician (PCP) from 08/16/2021 stating that R1 is refusing to apply the compression stocking.

Page 2 of 8.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 26-AS-20210318093226

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 07/06/2023

NARRATIVE

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LPA Marrufo interviewed 8 residents, 3 resident responsible parties (for 3 out of the 8 interviewed residents who were from memory care), and 10 care giver staff, and 3 kitchen staff.

During interview, resident R1 stated that the facility staff follow R1’s physician’s orders. 6 out of 8 interviewed residents stated the facility staff follow their physician’s orders. 1 interviewed resident did not respond to LPA’s questions. 1 out of 3 interviewed responsible party refused to be interviewed. 2 out of 3 interviewed responsible parties stated facility staff follow physician’s orders.

9 out of 10 interviewed facility staff stated staff follow resident’s physician’s orders. 1 out of 10 interviewed staff stated staff do not follow R2’s physician’s orders for R2’s compression stockings.

LPA Marrufo reviewed R2’s Intervention Logs for January through March 2021. The Intervention Logs indicate that staff assisted with R2’s compression stocking each day of the month from January through March 2021. Staff S1 stated R2 is deceased and is no longer at the facility.

The Medication Technician (Med Tech) Schedule for January through March 2021 indicates that in Assisted Living there is a Med Tech scheduled in the AM shift and another in the PM shift; in Memory Care, there is a Med Tech scheduled in the AM shift and another in the PM shift each day of the month.

The Staff Schedule for January through March 2021 indicates there are between 12-14 staff scheduled each day of the month.

R1 stated during interview that staff meet the supervision needs of the residents. 6 out of 8 interviewed residents stated the staff meet the supervision needs of the residents. 1 out of 8 interviewed residents did not respond to LPA’s questions during interview. 1 out of 3 interviewed reporting parties refused to be interviewed. 2 out of 3 interviewed reporting parties stated the staff meet the supervision needs of the residents.

Page 3 of 8.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 26-AS-20210318093226

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 07/06/2023

NARRATIVE

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10 out of 10 interviewed staff stated the staff meet the supervision needs of residents.

R1’s Intervention Log from January through March 2021 indicates all interventions are recorded as completed each day except for the dinner meal on the last day of each month.

R2-R4’s Intervention Logs from January through March 2021 indicate all interventions are recorded as completed each day except for the dinner meal on the last day of each month.

R1 stated during interview that staff assist residents with activities of daily living. 5 out of 8 residents stated staff assist residents with activities of daily living. 1 out of 8 residents stated to not know if staff assist residents with activities of daily living. 1 out of 8 residents did not respond to LPA’s questions.

1 out of 3 interviewed responsible parties refused to be interviewed. 2 out of 3 interviewed responsible parties stated staff assist residents with activities of daily living.

10 out of 10 interviewed staff stated staff assist residents with activities of daily living.

R1’s resident record contains an Introductory Letter from a podiatrist (Pod1) and a notice signed by R1’s responsible person stating that podiatry services will not be covered by R1’s insurance policy.

A facility Notice dated 02/24/2021 states that the beautician will resume service at the facility for both assisted living and memory care residents and will follow COVID protocols, including wearing a face shield and double masks. The Notice states the beauty salon services will be by appointment only and provides a telephone number to schedule an appointment.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 26-AS-20210318093226

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 07/06/2023

NARRATIVE

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The Podiatry Schedules for November 2020 through February 2021 (LPA did not obtain a copy of the January 2021 Podiatry Schedule) each have the word “postponed” written on them. R1 is listed on the roster of residents who had podiatry visits scheduled each month. The Podiatry Schedule from March 2021 includes R1 on the roster of residents with scheduled podiatry visits.

R1 stated during interview that staff assist residents with basic services. 5 out of 8 residents stated staff assist residents with basic services. 1 out of 8 residents stated to not know if staff assist residents with basic services. 1 out of 8 residents did not respond to LPA’s questions.

1 out of 3 interviewed responsible parties refused to be interviewed. 2 out of 3 interviewed responsible parties stated staff assist residents with basic services.

9 out of 10 interviewed staff stated staff assist residents with basic services. 1 out of 10 interviewed staff stated staff do not assist residents with basic services.

R1’s Physician’s Report states R1 is able to feed self.

R1’s Visual/Bedside Individual Service Plan Report states R1’s meals will be prepared by the facility and R1 prefers full portions to meals. The report states R1 is independent with dinning and should be observed for any changes in R1’s level of independence with dinning.

R1-R4’s Intervention Logs from January through March 2021 indicate staff assisted the residents with meals for every meal except for dinner on the last day of each month.

The Production Summary Worksheet with Temperatures Log records cooking temperatures of at least 140 F and up to 160 F for all cooked foods from November 2020 through March 2021.

Page 5 of 8.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 26-AS-20210318093226

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 07/06/2023

NARRATIVE

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The facility Menu for December 2020 through January 2021 indicate that breakfast, lunch, and dinner meals are served each day. Breakfast meals offer choices of eggs. Lunch and dinner meals offer salads, soups, a main course, sandwiches, and dessert options.

Witness 1 (W1) provided photographs to LPA Marrufo of a bowl with leafy greens, a disposable tray with an enchilada and refried beans, and another disposable tray with corn and sauced meat meal.

R1 stated during interview that staff provide meals of quality and quantity to meet the needs of the residents. 5 out of 8 residents stated staff provide meals of quality and quantity to meet the needs of the residents. 1 out of 8 residents stated to not know if staff provide meals of quality and quantity to meet the needs of the residents. 1 out of 8 residents did not respond to LPA’s questions.

1 out of 3 interviewed responsible parties refused to be interviewed. 2 out of 3 interviewed responsible parties stated staff provide meals of quality and quantity to meet the needs of the residents.

10 out of 10 interviewed staff stated staff provide meals of quality and quantity to meet the needs of the residents.

LPA Marrufo interviewed 3 kitchen staff. 3 out of 3 kitchen staff stated the facility serves warm meals to residents, the meals are served with portions of a sufficient size for the residents, and residents can ask for seconds, including if the residents are in their living units.

LPA Marrufo observed the heater coils used to keep food warm in the kitchen and the heater carts used to transport the meals to the residents while maintaining the meals at a warm temperature. LPA Marrufo observed there to be a microwave in the kitchen, which 3 out of 3 interviewed kitchen staff stated is used to reheat the meals if the meals have become cold.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 26-AS-20210318093226

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 07/06/2023

NARRATIVE

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R1’s Physician’s Report states R1 is able to take care of R1’s own toileting needs.

R1’s Visual/Bedside Individual Service Plan Report states R1 is independent with assistance to the bathroom and is continent of bladder and bowel.

R1’s Intervention Log for January through March 2021 states staff assisted R1 with all care interventions for Bladder Continence, Bowel Continence, Grooming, Assistance to Bathroom, and Laundry.

R2-R4 Intervention Logs for January through March 2021 states staff assisted each resident with all care interventions for Bladder Continence, Bowel Continence, Grooming, Assistance to Bathroom, and Laundry.

R1 stated during interview that staff accord the residents with dignity. 5 out of 8 residents stated staff accord the residents with dignity. 2 out of 8 residents did not respond to LPA’s questions.

1 out of 3 interviewed responsible parties refused to be interviewed. 2 out of 3 interviewed responsible parties stated staff accord the residents with dignity.

10 out of 10 interviewed staff stated staff accord the residents with dignity.

The Facility Apartment Cleaning Matrix Schedule, which was last updated 11/16/2022, indicates there are three cleaning staff assigned to clean all the bedrooms in 4 out of 4 floors in the building as well as the common areas of each floor.

LPA Marrufo conducted a telephone interview with the Podiatrist (Pod1) on 06/30/2023. Pod1 was listed on the facility Podiatry schedule from November 2020 to February 2021 as the podiatrist. Pod1 stated to have provided podiatry services to the facility residents about once or twice a month. Pod1 stated to not remember to have provided podiatry services to R1.

Page 7 of 8.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 26-AS-20210318093226

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 07/06/2023

NARRATIVE

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Pod1 stated that Pod1’s instruments were sanitized in an antiseptic solution. Pod1 stated to use hand sanitizer between working with residents. Pod1 stated to only wear gloves when working with a resident if there was a break in the resident’s skin.

Pod1 stated to use a small battery-powered vacuum when cleaning up after providing podiatry care with residents. Pod1 stated to try to put a garbage can underneath the feet of the residents if there was a garbage can available. Pod1 stated to very rarely get complaints about toenails being left behind after podiatry visits. Pod1 stated the staff told Pod1 not to worry about the toenail clippings and would clean them up afterwards.

R1 stated during interview that staff keep the facility clean. 5 out of 8 residents stated staff keep the facility clean. 2 out of 8 residents did not respond to LPA’s questions.

1 out of 3 interviewed responsible parties refused to be interviewed. 2 out of 3 interviewed responsible parties stated staff keep the facility clean.

10 out of 10 interviewed staff stated staff keep the facility clean.

During visits, LPA Marrufo observed the living units for the 8 out of 8 interviewed residents. LPA Marrufo did not observe any toenail clippings in any of the observed living units. LPA Marrufo did not observe any signs of uncleanliness in the observed living units.

Based on information from interviews conducted with staff, residents, and other parties, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Kathleen Olson and a copy of the report was provided.

Page 8 of 8. END REPORT.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8