435202623-10-7-2021-26-AS-KHOS-C7QNZU-20211012105454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 10/07/2021
Date Signed: 10/07/2021 04:01:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/01/2021 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20211001163035

FACILITY NAME:	SUNRISE ASSISTED LIVING OF PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	GRACE KOMASAKA		FACILITY TYPE:	740
ADDRESS:	2701 EL CAMINO REAL		TELEPHONE:	(703) 273-7500
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	97	CENSUS: 80	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Grace Komasaka		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident physically assaulted another resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Grace Komasaka.

During visit, LPA Marrufo conducted interviews with residents R1-R6 and staff S1-S11. LPA obtained copies of Appraisal/Needs and Service Plans and Emergency Contact forms for R1-R6 as well as Progress Notes from 09/29/2021. LPA Marrufo observed the Reminiscence Floor, including the television room, activity room, and hallway.

Staff S10 stated during interview to have observed R1 push R2 in the hallway, and observed R1 sustain a bruise to R1's head when R1 fell after pushing R2. S10 stated that R1 was sitting in a chair in the television room when R2 walked past R2 in the hallway near the television room. See LIC9099-C for more information.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20211001163035

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 10/07/2021

NARRATIVE

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S10 stated that R2 was in an agitated state, yelling and cursing in the hallway prior to R1 pushing R2. S10 stated that R1 has a behavior of being agitated. S10 stated that R1 got up and pushed R2 too quickly for S10 to respond and prevent R1 from pushing R2. S10 stated that staff assessed R1 and R2 after the fall and 911 was called immediately afterwards. S10 stated during interview that paramedics determined that R1 did not have to go to the emergency room for the bruise on R1's head.

S11 stated during interview to have been in the kitchen during the incident and did not observe the incident. S11 states that S11 and other staff helped separate both residents afterwards and called 911 for the residents.

Staff S6-S9 stated to have been present at the facility during the incident, but did not observe the incident when it occurred. S6-S9 stated that they responded to the incident after it occurred and stated that the residents were separated from one another, assessed for injuries, and 911 was called for the residents. S6-S9 stated that paramedics determined that neither R1 nor R2 needed to be taken to the emergency room.

Staff S1-S5 stated that they were told by staff from the previous shift about the incident involving R1 and R2, and they were told to monitor each resident and assist in redirecting each resident should the residents become agitated.

Progress Notes from 09/29/2021 state that R1 got up and pushed R2 so suddenly that it was not able to be prevented, but staff were able to separate them as soon as possible, apply first aid on R1, and call 911. During visit, LPA conducted wellness checks and interviews with residents R1-R6.

Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Grace Komasaka and a copy of the report was provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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