496803412-10-21-2020-21-AS-CMAZ-BURKU5-20201026081209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803412
Report Date: 10/19/2020
Date Signed: 10/21/2020 08:29:45 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
03/30/2020 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200330133312

FACILITY NAME:	SUNRISE OF PETALUMA		FACILITY NUMBER:	496803412
ADMINISTRATOR:	CARLSON, ERIN		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DR		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS: 63	DATE:	10/19/2020
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Erin Carlson - Executive Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility not following their Program Plan

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst (LPA) Fernandes-Goes made contact on this date, by phone, and conducted an unannounced virtual visit with Executive Director - Erin Carlson, for the purpose of close the complaint due to COVID-19 precautions.

LPA Fernandes-Goes virtually toured the facility; conducted interviews; acquired documentation; and made observations of the facility. LPA reviewed documents for facility COVID-19 program plan and staff training submitted by email from Erin Carlson Executive Director on 4/13/2020, LPA made observations on 4/1/2020; and interviewed Executive Director Erin Carlson during virtual visit. In addition, LPA interviewed 7 staff on 5/4, 9/30, and 10/5/2020 and learned that facility staff has been trained and is following the Department and LPH guidelines regarding COVID-19 mitigation. (Continue LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (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)

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Control Number 21-AS-20200330133312

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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During virtual visit facility had postings through out of the facility as requested through the Department guidelines and some other postings needed were recommended by HFEN Nurse Magri & LPA to ensure facility compliance. Staff training for COVID-19, PPE, and facility sick policy were conducted during different days in the month of March and April 2020. According to the Department PIN #s 20-04 dated 3/5/2020 & 20-07 dated 3/13/2020 facility have followed guidelines at sometime in March 2020 and staff trainings needed were conducted in March & April 2020. LPA wasn’t able to prove or disprove that facility was not following program plan at this time.

A finding that the complaint allegation of "Facility not following their Program Plan” is 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 Martinez	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: (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)

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