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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803412
Report Date: 10/19/2020
Date Signed: 10/21/2020 08:45:11 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2019 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20191119094218
FACILITY NAME:SUNRISE OF PETALUMAFACILITY NUMBER:
496803412
ADMINISTRATOR:CARLSON, ERINFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRTELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 63DATE:
10/19/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erin Carlson, Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff failed to meet residents care needs.
Staff yell at the residents.
Staff handles residents in a roughly manner.
Night staff is sleeping during their shift.
Residents are left in soiled diapers for extended periods of time.
Staff withholding food from residents.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst Fernandes-Goes conducted a telephone visit due to COVID-19 unannounced followed by a virtual visit for the purpose of closing the investigation and met with Erin Carlson – Executive Director.

On 2/3/2020 at 7:45 AM, LPA Fernandes-Goes toured the facility; acquired documentation; made observations of the facility; and conducted interviews on 11/20/2019, 2/3, 2/6, and 5/4/2020. During documentation review on file and complainant, resident’s POAs and staff interviews, LPA learned that facility has enough staff to meet the needs of the residents and is aware of their needs. In addition, there have been some staff that was shifted around two memory care areas – Courtyard and Garden due to matching staff and resident’s compatibility. (Continue LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2019 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20191119094218

FACILITY NAME:SUNRISE OF PETALUMAFACILITY NUMBER:
496803412
ADMINISTRATOR:CARLSON, ERINFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRTELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 63DATE:
10/19/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erin Carlson - Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility is unsanitary.

Residents have access to hazardous materials.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst Fernandes-Goes conducted a telephone visit due to COVID-19 unannounced followed by a virtual visit for the purpose of closing the investigation and met with Erin Carlson – Executive Director.

On 11/22/2018 at 7:45 AM, LPA Fernandes-Goes arrived at the facility for the purpose of opening a complaint investigation. On 2/3/2020 LPA continued the investigation and toured the facility at 8:45 AM; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with Assistant Executive Director Kristen Korfhage, LPA observed that on memory care Courtyard side of the facility three resident’s bedrooms had a dirty carpet (photos on file) and one bedroom had a strong smell of urine along with stains on the carpet. (Continue LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20191119094218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SUNRISE OF PETALUMA
FACILITY NUMBER: 496803412
VISIT DATE: 10/19/2020
NARRATIVE
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LPA also observed several toxins inside an unlocked, kitchen cabinet under the sink which were accessible to residents on Courtyard memory care side during facility tour on 2/3/2020 (photos on file).

According to complaint allegation "Residents have access to hazardous materials”, and “Facility is unsanitary” there were related observations made during visit. Based on LPAs' observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20191119094218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SUNRISE OF PETALUMA
FACILITY NUMBER: 496803412
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2020
Section Cited
CCR
87705(f)(2)
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87705(f)(2)Care of Persons with Dementia.The following items shall be made inaccessible to residents with dementia:... toxic substances such as ...cleaning supplies &disinfectants.This requirement isn'tmet as evidence
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Licensee to ensure that toxins, dangers items, & medications are inaccessible at all times. Licensee to remove and lock all items specified in this Reg. through out of memory care immediately & provide training to
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by:**Based on observation facility staff didnt comply w/this reg. to maintain cleaning supplies inaccessible in 1 of 2 memory care kitchens which poses an immediately risk to residents in care.LPA observed toxins under unlocked kitchen sink. (see pictures)
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to staff regarding 8770(f). Facility to submit written self-certification of all dangers items have been removed by POC due date of 10/20/20 & proof of staff training with sign-in sheet, trainer, and topics covered by in order to clear this citation.
Type B
11/02/2020
Section Cited
CCR
87703(a)
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87303(a)Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: *** Based on observation the facility didnt comply
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Facility to ensure that it is in good repair and clean at all times; Facility to submit self certification that facility has facility clean of odors, desinfected, and clean carpets through out of the facility
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w/this regulation to maintain 4 carpet room clean & free from odors which poses a health & safety risk to residents in care. LPA toured memory care w/ Ass. Administrator and observed residents' rooms. (see pict)
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to CCL by POC date of 11/2/2020 in order to clear this citation.
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: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20191119094218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SUNRISE OF PETALUMA
FACILITY NUMBER: 496803412
VISIT DATE: 10/19/2020
NARRATIVE
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Facility has awake staff at night shift as per facility program and policy. LPA observed breakfast and lunch during visit that occurred on 2/3/2020 and did not observed food at that time being withhold from residents. In addition, residents are to be changed as needed during all shifts including overnight shift – NOC shift. Based on documentation reviewed (on file), interviews (see LIC 812s), and observations LPA wasn’t able to prove or disprove the allegations stated above.

A finding that the complaint allegations of “Staff failed to meet residents care needs.
Staff yell at the residents.”; “Staff handles residents in a roughly manner.”; “Night staff is sleeping during their shift.”; “Residents are left in soiled diapers for extended periods of time.”; and “Staff withholding food from residents.” are unsubstantiated meaning that although the allegation 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 during this inspection.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5