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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002959
Report Date: 07/17/2025
Date Signed: 07/17/2025 11:34:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250423134418
FACILITY NAME:SUNDIAL ASSISTED LIVINGFACILITY NUMBER:
455002959
ADMINISTRATOR:ELIZABETH AMLINFACILITY TYPE:
740
ADDRESS:395 HILLTOP DRIVETELEPHONE:
(530) 241-2900
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:65CENSUS: 32DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sherrill Denny, LVN and Michelle Decoito, Business Office Manager.TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not taking steps to prevent the spread of a communicable disease.
Staff do not ensure staff are properly trained.
Staff do not ensure facility has adequate Personal Protective Equipment (PPE) supplies.
INVESTIGATION FINDINGS:
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On July 17, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/23/25. LPA Adkison met with Sherrill Denny, LVN and Michelle Decoito, Business Office Manager, and explained the purpose of the visit.

Allegation: Staff are not taking steps to prevent the spread of a communicable disease.
withSherrill
During the interview process, the Administrator, Wellness Services Director and several staff persons were interviewed. Documents were obtained to include Physicians Reports, Emergency Information, Appraisals and Needs, Admission Agreements, hospital notes, staff person names and contact numbers.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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 5
Control Number 59-AS-20250423134418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNDIAL ASSISTED LIVING
FACILITY NUMBER: 455002959
VISIT DATE: 07/17/2025
NARRATIVE
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During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA), which is highly contagious. It was stated that Resident 1 was in the facility with MRSA during the month of April 2025. It was reported that Resident 2 was in the facility with MRSA during the month of June 2025. It was stated that initially, staff were not given the information or directive that residents had MRSA.

Based on investigation observations, interviews, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Allegation: Staff do not ensure staff are properly trained.

During the interview process, the Administrator, Wellness Services Director and several staff persons were interviewed. Documents were obtained to include Physicians Reports, Emergency Information, Appraisals and Needs, Admission Agreements, hospital notes, staff person names and contact numbers.

During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). It was stated by several persons that the medication technicians and care providers were not provided with training regarding providing care and supervision with residents that have MRSA. It was reported that management gave a verbal instruction; however, no formal training.

Training did not include documentation from an appropriately skilled professional stating what aspects of care will be delegated to facility staff responsible for the care and that the appropriately skilled professional will train those staff persons prior to delegating care.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Report Continued on additional LIC 9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 59-AS-20250423134418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNDIAL ASSISTED LIVING
FACILITY NUMBER: 455002959
VISIT DATE: 07/17/2025
NARRATIVE
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Allegation: Staff do not ensure facility has adequate Personal Protective Equipment (PPE) supplies.

During the interview process, the Administrator, Wellness Services Director, and several staff persons were interviewed. Documents were obtained to include Physicians Reports, Emergency Information, Appraisals and Needs, Admission Agreements, hospital notes, staff person names and contact numbers.

During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). Staff were advised to use gloves; however, were not told of the importance to use Personal Protective Equipment (PPE) to include gloves, mask, gown and foot booties.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20250423134418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNDIAL ASSISTED LIVING
FACILITY NUMBER: 455002959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
87468.2(a)(4)
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Personal Rights - In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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POC – The administrator agrees to ensure that all staff providing care and supervision are aware that the residents have/had MRSA. The administrator shall submit to the licensing agency that she agrees with the regulation by end of business 07/18/2025
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure that all staff were aware that residents had Methicillin-Resistant Staphylococcus Aureus (MRSA), or other serious infection. This poses an immediate risk to residents in care.
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The administrator has since ensured that MRSA training was provided to all medication technicians and care providers. The administrator shall submit to the licensing agency a sign in sheet signed by the providers that they did receive training by end of business 07/18/2025
Type A
07/18/2025
Section Cited
CCR
87411(a)
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Personnel Requirements, General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not provide formal training to staff regarding Methicillin-Resistant Staphylococcus Aureus (MRSA). This poses an immediate 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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20250423134418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNDIAL ASSISTED LIVING
FACILITY NUMBER: 455002959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
87470(b)(2)(A)
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87470(b)(2)(A) - Infection Control Requirements - In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents…
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The licensee/administrator shall ensure that PPE is always provided to staff. Licensee/administrator will put in writing to the licensing agency that she agrees with ensuring that PPE is always available to staff by end of business 07/18/2025.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure that staff were provided with all PPE supplies during a time when a resident had MRSA. This poses an immediate 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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5