Community Care Licensing

SUPERVISOR'S NAME: Jackie Jin TELEPHONE: (714) 319-3786 LICENSING EVALUATOR NAME: David Marrufo TELEPHONE: (650) 380-0519 LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022

Document Has Been Signed on 06/22/2022 05:00 PM - It Cannot Be Edited

FACILITY NAME: SONNET HILL	FACILITY NUMBER: 435202780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/23/2022 Section Cited	1 2 3 4 5 6 7	87465(c)(2) Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff
	8 9 10 11 12 13 14	designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not being met as evidenced by: Based on record review, facility stopped giving R1’s medication without a doctor’s order to stop when R1 was not eating for 48 hours. This poses an immediate risk to the health and safety of resident in care.	8 9 10 11 12 13 14	submit copies of trainings to CCLD.
Type B 06/29/2022 Section Cited	1 2 3 4 5 6 7	87224(d)(1) Eviction Procedures: (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
	8 9 10 11 12 13 14	(1) The notice to quit shall include the following information: (B) to (D) This requirement is not being met as evidenced by: Based on record review, the eviction notice dated 2/10/22 did not have information on resources, the right to file a complaint, and unlawful detainer language.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Jackie Jin TELEPHONE: (714) 319-3786 LICENSING EVALUATOR NAME: David Marrufo TELEPHONE: (650) 380-0519 LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022

Document Has Been Signed on 06/22/2022 05:00 PM - It Cannot Be Edited

FACILITY NAME: SONNET HILL	FACILITY NUMBER: 435202780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/29/2022 Section Cited	1 2 3 4 5 6 7	87507(a) Admission Agreements: (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by: Based on interview and record review, the licensee did not complete a written admission agreement with R1’s representative which poses a potential risk to the health of the resident in care.	8 9 10 11 12 13 14
Type B 06/29/2022 Section Cited	1 2 3 4 5 6 7	87224(f) Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by: Based on record review, CCL did not receive a copy of R1’s eviction notice in February.
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SUPERVISOR'S NAME: Jackie Jin TELEPHONE: (714) 319-3786 LICENSING EVALUATOR NAME: David Marrufo TELEPHONE: (650) 380-0519 LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022