496803737-10-7-2021-21-AS-KMOA-C82RXG-20211022132444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803737
Report Date: 10/07/2021
Date Signed: 10/07/2021 09:41:01 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
09/07/2021 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20210907103928

FACILITY NAME:	SUNRISE VILLA SANTA ROSA		FACILITY NUMBER:	496803737
ADMINISTRATOR:	BURKE, TRACY		FACILITY TYPE:	740
ADDRESS:	4225 WAYVERN DR		TELEPHONE:	(707) 538-2590
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	114	CENSUS: 61	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director, Krystal Jenkins		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Staff did not communicate the change in resident's health condition to their authorized representative

INVESTIGATION FINDINGS:

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Licensing program analyst (LPA), Erik Gonzalez Campos conducted a complaint investigation regarding the allegation mentioned above and met with acting executive director Krystal Jenkins to deliver complaint findings.

LPA conducted interviews with staff and witnesses as well as performed a review of resident records.
Based on a review of records submitted to Community Care Licensing by the facility it was determined that 5 residents who were COVID tested on 08/26/2021 received positive results on 08/31/2021 and that one resident who tested on 08/31/2021 received a positive result on 09/01/2021. Facility provided records stating that the responsible parties for 5 residents were notified on 08/31/2021 and for 1 resident on 09/01/2021. Furthermore, S1 stated during interview that they spoke with 6 out of 6 responsible parties following the positive COVID results.

Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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-20210907103928

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 VILLA SANTA ROSA	FACILITY NUMBER: 496803737
	VISIT DATE: 10/07/2021

NARRATIVE

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Based on the interviews, record review, and information obtained during the investigation, the allegation that Staff did not communicate the change in resident's health condition to their authorized representative is UNSUBSTANTIATED.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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