435202623-10-29-2021-26-AS-KHOS-C8KMDA-20211108083048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 10/29/2021
Date Signed: 10/29/2021 11:43:23 AM

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
09/04/2019 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20190904121731

FACILITY NAME:	SUNRISE ASSISTED LIVING OF PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	SAULNIER, AMY		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:	10/29/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Grace Komasaka		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff neglect resulted in resident sustaining a fracture
Facility failed toileting and hygiene needs
Staff left resident in soiled clothing and bedding
Staff did not properly dispose of resident's diapers

INVESTIGATION FINDINGS:

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

On 09/04/2019, the Department received an investigation with the above allegations. The Department conducted investigation visits at the facility on 09/05/2019, 11/04/2019, 11/20/2019, and 10/07/2021. The Department conducted interviews with staff and witnesses and reviewed records.

See LIC9099-C for more information. Page 1 of 4.

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: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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 9

Control Number 26-AS-20190904121731

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: 10/29/2021

NARRATIVE

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Progress Notes from 04/01/2019 state that facility staff observed resident R1 with swelling on left hand. Facility staff faxed R1’s physician and notified R1’s Responsible Party (RP). Facility staff requested a mobile x-ray to rule out fracture. The Progress Notes from 04/02/2019 states the Wellness Nurse on duty reported to RP that R1’s x-ray result indicate that R1 had a fracture on left wrist. R1’s primary care physician ordered a stronger dose of pain reliever and provided a referral to Orthopedics, and stated that if R1’s pain persists, then staff should take R1 to ER.

The Incident Report filed by the facility on 04/04/2019 states that on 04/03/2019, facility staff observed R1 with left hand swelling. The Incident Report states that an x-ray was done for R1 and indicated R1 had a fracture. The Incident Report does not indicate which staff observed the swelling on R1’s hand, where R1 was located when staff first observed the swelling, or how R1’s left hand become swollen.

In a letter from RP to the administrator of the facility dated 07/25/2019, the RP states that on April 2019, facility staff S1 notified RP that the A.M. shift found R1 with R1’s mattress askew and R1’s wrist swollen. RP further states that R1 had had nighttime issues including walking at night and an earlier fall.

On 04/14/2019, R1’s Appraisal/Needs and Services Plan was updates to include that R1’s bedroom would have a motion sensor installed that will notify when R1 is walking, and staff will check on R1 when notified. The prior entry on R1’s Appraisal/Needs and Services Plan, dated 04/16/2018, states that R1 has trouble sleeping, and staff are to report if R1 is awake or wandering at night, and R1 has a PRN to assist R1 in sleeping if R1 is up and wandering at night. The Appraisal/Needs and Service Plan was last completed on 04/28/2019 and included as a Special Instruction that R1 will have a private companion everyday from 4:00PM-12:00 midnight.

Page 2 of 4.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 26-AS-20190904121731

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: 10/29/2021

NARRATIVE

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R1’s Appraisal/Needs and Services Plan indicates was a fall risk and had a history of falls, including on 04/27/2018, 12/08/2018, 02/27/2019, 05/13/2019, and 07/12/2019. The Appraisal/Needs and Services Plan does not state that R1 needs hourly checks at night.

R1’s Physician’s Report, dated 02/26/2019, indicate that R1 is ambulatory, is able to independently transfer to and from bed, has mental conditions of being confused/disoriented, wandering behavior, and sundowning behavior.

During interview, staff S1 and S2 stated that facility staff would check on R1 every hour and a half to two hours. Staff S3 and S4 stated that staff check on residents every hour to two hours.
Residents R2-R7 stated during interview that they did not have any problems with staff or any issues with care at the facility.

R1’s Physician’s Report, dated 02/26/2019, states that R1 is ambulatory, able to transfer in and out of bed independently, able to care for own toileting needs, not able to bathe self, and not able to dress/groom self.

R1’s Appraisal/Needs and Services Plan has an entry from 09/27/2016 that states R1 is continent of bladder and bowel.

R1’s Task Schedule for April 2019 states that staff completed tasks for Bladder Continence and Bowel Continence three times a day everyday throughout the month of April 2019. The Bathing Task requires staff to provide a 1 person assistance on Sunday, Wednesday, and Saturday mornings. The Task Schedule reflects that staff fulfilled the Bathing Task at the required times. The Grooming task was completed at least once a day, every day in April 2019.

Page 3 of 4.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 26-AS-20190904121731

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: 10/29/2021

NARRATIVE

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5 interviewed staff stated that facility staff provided for R1’s toileting and hygiene needs. 1 witness stated to have observe R1 with bad hygiene and also stated R1 resisted staff when taking showers. 1 more witness stated to have observed that 2-3 staff would shower R1 and R1 resisted staff when showering.

R1’s task schedule for April 2019 states that staff are tasked with providing laundry assistance for R1 every Friday night shift. The task schedule states that facility staff completed the task throughout the month of April 2019.

6 interviewed staff stated that staff would conduct checks on R1 every two hours and did not observe staff to leave R1 in soiled clothing and bedding. 1 witness stated that staff would change R1’s clothing and bedding daily.

2 interviewed staff stated that staff would pick up R1’s diapers off the floor in the mornings. 1 of the 2 staff stated that R1 had a habit of sometimes removing the diapers at night. 1 out of 2 witnesses stated to have observed diapers on the floor. 1 out of 2 witnesses stated to not recall if R1’s diapers were left on the floor.

Based on interview with facility staff and witnesses and on review of records, the Department finds the above allegations to be unsubstantiated, meaning there is not a preponderance of evidence to prove the allegations did or did not occur.

This report was reviewed with Administrator Grace Komasaka and a copy of the report and appeal rights were provided.

Page 4 of 4.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 9

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
09/04/2019 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20190904121731

FACILITY NAME:	SUNRISE ASSISTED LIVING OF PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	SAULNIER, AMY		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:	10/29/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Grace Komasaka		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff failed to seek medical attention in a timely manner for resident.

INVESTIGATION FINDINGS:

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The facility filed an incident report on 04/04/2019 for an incident occurring on 04/03/2019 involving resident R1 experiencing left hand swelling. The incident report states that R1 was sent to the hospital on the same day as the incident, was given an x-ray at the hospital, and was diagnosed with a fracture. The incident report states R1 was returned to the facility on the same day and facility staff were informed for the care of the splint.

See LIC9099-C for more information. Page 1 of 2.

Unfounded

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: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 26-AS-20190904121731

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: 10/29/2021

NARRATIVE

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Progress Notes for R1 dated 04/01/2019 at 13:18 state facility staff noticed swelling on R1’s left hand. The Progress Note states staff faxed R1’s medical doctor, notified R1’s responsible party (RP), and requested mobile x-ray to rule out fractures. Progress Notes for R1 dated 04/02/2019 at 14:15 states R1’s primary care physician ordered a stronger dose of pain reliever and referral to Orthopedics, but if pain persists, then staff should send R1 to ER. Progress Notes for 04/03/2019 15:38 state that at around 10:50 AM, R1 still complaint of left hand pain and pain killing medication was ineffective. R1’s swelling in left hand increased and staff sent R1 to hospital for further intervention. An additional note at 15:39 states R1’s one-on-one companion and sister took R1 to hospital. Progress notes for 04/03/2019 15:50 state that at 3:50 PM, R1 was transported to the hospital. Staff observed R1 with unsteady balance. R1 denied any pain. The Progress Notes states RP requested staff not remove R1’s splint until further notice. Progress Note on 04/04/2019 12:11 states R1 returned from Hospital ER with left arm splint intact.

The Progress Note for 07/15/2019 includes a late entry for 07/12/2019 that states that R1 had a fall on 07/12/2019. The Progress Note states resident was seen suddenly tripping and falling on a sink counter inside R1’s apartment. Staff conducted assessment immediately and noted no signs of pain or discomfort. R1 denied pain and range of motion done on all extremities and were appropriate to baseline. On a follow up note for 07/15/2019, Day 1 post fall, R1 was noted with a bruise-like discoloration on right part of back and was also noted with more leaning to R1’s right. R1’s Primary Care Physician and RP were notified. Staff spoke to PCP office and sent an order for x-ray to rule out fracture.

An x-ray exam document indicates an x-ray was done for R1 on 07/16/2019.

Based on review of records, the above allegation is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Administrator Grace Komasaka and a copy of the report was provided. Page 2 of 2.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 9

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
09/04/2019 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20190904121731

FACILITY NAME:	SUNRISE ASSISTED LIVING OF PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	SAULNIER, AMY		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:	10/29/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Grace Komasaka		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff did not notify resident's authorized representative of an injury

INVESTIGATION FINDINGS:

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Resident R1’s responsible party (RP) stated in a letter dated 07/25/2019 in a letter addressed to the Administrator of the facility at that time that R1 had a fall on 07/12/2019 and that staff notified RP of R1’s fall on 07/15/2019. Progress Notes for R1 dated on 07/15/2019 indicate a late entry for an incident involving R1 falling on 07/12/2019. The Progress Note states that RP was notified of R1’s fall, however, the Progress Note does not state the date on which RP was notified of R1’s fall. The administrator at that time stated in an email addressed to RP on 07/19/2019 that R1 had a fall on 07/12/2019. The administrator stated in the email that there was a miscommunication amongst the team members as to who was to notify RP about the fall and that the team members involved with R1’s fall had been given in-service training about fall protocol.

See LIC9099-C for more information. Page 1 of 2.

Substantiated

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: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 26-AS-20190904121731

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: 10/29/2021

NARRATIVE

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The Sunrise Learning Support Training Participation Log dated 07/16/2019 indicates that six staff received training for Incident Reporting. The Training Participation Log has an accompanying Internal Incident Reporting policy which states, “The Executive Director must notify the resident’s health care practitioner and the resident’s representative as soon as possible following each resident-specific incident during daytime hours, or as outlined in the resident’s Individual Service Plan. The Fall Management Program guide states on page 12, Section V When a Resident Falls – Fall Management A. Immediate Steps, “The following steps should be implemented when a resident sustains a fall:…Notify the resident’s legal representative.”

The Performance Counseling and Improvement Plan for Corrective Action for staff S5, dated 07/18/2019, states that on 07/12/2019, S5 failed to follow department policy. The document states S5 was notified of a fall that occurred on 07/12/2019 and failed to follow the facility’s incident procedure.

During interview, R1’s private care giver (PC1) stated that R1 sustained a fall on the evening of 07/12/2019 and RP visited R1 the next day, but staff did not inform RP of the fall. When PC1 came to work on 07/15/2019 to provide care for R1, PC1 noticed that R1’s back was bruised. PC1 brought the bruise to the attention of facility staff and asked the staff if they had notified RP. PC1 stated that the staff stated they had not yet notified RP and began to blame one another for not notifying RP. PC1 then called RP and notified RP of R1’s bruise.

Based on interviews and review of records, there is a preponderance of evidence to prove the allegation did occur. Therefore, the allegation is substantiated.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC9099-D for more information. This report was reviewed with Administrator Grace Komasaka and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 9 of 9

Control Number 26-AS-20190904121731

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/05/2021 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of	1 2 3 4 5 6 7	Deficiency was corrected Licensee conducted in-service training for incident reporting on 07/16/2019.
	8 9 10 11 12 13 14	activities related to care or services, including ongoing evaluations, as appropriate to their needs. This deficiency was not met as evidenced by: Licensee did not ensure that R1’s Responsible Party was notified of R1’s fall and bruising to R1’s back. R1 sustained a fall resulting in bruising on 07/12/2019, and R1’s private care giver observed the bruising and was the first to notify R1’s Responsible Party on 07/15/2021, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

Page: 8 of 9