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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803412
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:59:11 PM


Document Has Been Signed on 03/11/2022 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SUNRISE OF PETALUMAFACILITY NUMBER:
496803412
ADMINISTRATOR:LAYTON, NATHANFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRTELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 75DATE:
03/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nathan Layton- AdministratorTIME COMPLETED:
04:58 PM
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On 3/11/2022 at approximately 2 pm Licensing Program Analyst (LPA) Hansen arrived unannounced at the facility to follow up on an incident report regarding a hospice resident (R1) residing in the memory care section of the facility who had sustained a broken leg.
On 2/27/22 around 7am the care manager went to R1s room to get her ready for the day and found resident complaining of left lower leg pain. Left foot appeared swollen and calf area disfigured. Hospice was notified immediately. Hospice nurse arrived, called POA (son) explained and recommended a mobile x-ray could be ordered or resident could be sent to Kaiser ER which would revoke hospice services. Son revoked hospice and sent resident to hospital. Care manager observed residents room showed no evidence of a fall taking place and resident was found in bed.
Resident sustained a fractured left tibia/fibula and UTI. Resident was put on a soft cast and treated for UTI. The hospital recommended discharge and the resident was put back onto hospice services and care and returned to facility.

LPA spoke with Administrator Nathan Layton regarding this incident and he informed the resident has returned from the hospital, R1's left leg is non-weight bearing. Facility is doing frequent checks and is to have hydration offered often.
R's pain is managed and is doing fine. POA visits at least twice a week.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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