496803412-12-22-2021-21-AS-BMOS-CA6QHW-20211229111149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803412
Report Date: 12/09/2021
Date Signed: 12/22/2021 10:14:21 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
11/05/2021 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20211105142023

FACILITY NAME:	SUNRISE OF PETALUMA		FACILITY NUMBER:	496803412
ADMINISTRATOR:	LAYTON, NATHAN		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DR		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS: 79	DATE:	12/09/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Nathan Layton, Administrator		TIME COMPLETED:	02:23 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not assist resident with prescribed medications.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of a subsequent complaint investigation resulting in delivering findings of the above allegations. LPA met with Nathan Layton, Administrator.

During the investigation PLA reviewed records, made observations at the facility and conducted interviews.

Staff did not assist resident with prescribed medications – LPA conducted interviews, reviewed records, and made observations during the investigation. Complainant alleges on the evening of 10/31/2021 there was no staff to give resident evening medications. LPA interviewed Administrator and nurse who corroborated with incident report received on 11/5/2021 that for this evening medication would be prepared and dispended by designated staff. Interview on 11/19/2021 with Administrator confirmed that the designated staff failed to give the resident their medication. Based on LPA’s interviews, and a review of records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
Continued on 9099-A

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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 3

Control Number 21-AS-20211105142023

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: 12/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/10/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs………. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to conduct an all staff training with staff that dispense medication to review facility policies to prevent future medication errors. Administrator agrees to submit date of training to CCL on 12/10/2021. Admin agrees to submit LIC 9098 and training sign in sheet to CCL by 12/17/2021.
	8 9 10 11 12 13 14	Based on LPAs record review and interviews the facility did not ensure evening medications were dispensed to resident in care, which poses an immediate 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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
11/05/2021 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20211105142023

FACILITY NAME:	SUNRISE OF PETALUMA		FACILITY NUMBER:	496803412
ADMINISTRATOR:	LAYTON, NATHAN		FACILITY TYPE:	740
ADDRESS:	815 WOOD SORREL DR		TELEPHONE:	(707) 776-2885
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	95	CENSUS:	DATE:	12/09/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:			TIME COMPLETED:	02:23 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Insufficient staffing to meet the needs of the resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of a subsequent complaint investigation resulting in delivering findings of the above allegations. LPA met with Nathan Layton, Administrator.

Insufficient staffing to meet the needs of the resident- Complainant alleges insufficient staffing on 10/31/21 due to medication error in which allegation above was substantiated. Based on LPA’s record review of staff schedule on 10/31/2021 facility had lead care manager on shift to dispense medications to memory care residents, review of care staff on facility staff schedule appears to be sufficient on this day. LPA conducted interviews with staff and residents confirming medication error as well as sufficient staff scheduled to meet the needs of residents in care. Although, complainant reports facility failed to have adequate staffing meet resident(s) needs, there was conflicting information gathered during interviews and record review. The allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3