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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200726
Report Date: 05/25/2022
Date Signed: 05/25/2022 12:35:58 PM

Document Has Been Signed on 05/25/2022 12:35 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNRISE CARE HOME IIFACILITY NUMBER:
019200726
ADMINISTRATOR:TAYAG, NANCY RFACILITY TYPE:
740
ADDRESS:1435 VIA LUCASTELEPHONE:
(510) 398-8677
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY: 6CENSUS: 6DATE:
05/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Nancy Tayag, AdministratorTIME COMPLETED:
12:50 PM
NARRATIVE
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On 5/25/2022 at 11:20 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct a Case Management visit. LPAs met with Administrator, Nancy Tayag and explained the purpose of the visit.

During the course of investigation for complaint (#15-AS-20210909122733), the following deficiency was observed.

Interview with staff indicated staff were aware of R1's four wounds; one sore on each heel, one on buttocks and one on right heel. Staff confirmed the wound was not healing and did not seek medical attention for R1's buttocks and leg. In addition, facility did not notify responsible party nor submitted an incident report to CCLD..

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Administrator. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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Document Has Been Signed on 05/25/2022 12:35 PM - It Cannot Be Edited


Created By: Lizette Francisco On 05/25/2022 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SUNRISE CARE HOME II
FACILITY NUMBER: 019200726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2022
Section Cited
CCR
87466

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OBSERVATION OF THE RESIDENT
The licensee shall ensure that residents are regularly observed for changes in physical....and that appropriate assistance is provided.....such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Administrator agrees to review regulation and obtain training with a vendor covering topic. By POC date, Administrator will submit a registration confirmation and self-certification letter on understanding of regulation to CCLD.
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This requirement is not met as evidenced by: Based on The Department's interviews, Licensee did not comply with the section cited above. Staff failed to seek medical attention once staff observed R1's wounds were not properly healing which poses an immediate health and safety risk to residents in care.
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Type B
05/30/2022
Section Cited
CCR87211(a)(1)

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REPORTING REQUIREMENTS
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days......
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Administrator agrees to review regulation and obtain training with a vendor covering topic. By POC date, Administrator will submit a registration confirmation and self-certification letter on understanding of regulation to CCLD.
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This requirement is not met as evidenced by: Based on the Department's interview and record review, Licensee did not comply with the section cited above. Staff did not notify R1's responsible party and did not submit incident report to CCLD which poses a potential health and safety risk to residents in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022


LIC809 (FAS) - (06/04)
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