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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002828
Report Date: 11/18/2021
Date Signed: 11/18/2021 02:16:20 PM

Document Has Been Signed on 11/18/2021 02:16 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SUNRISE SENIOR CAREFACILITY NUMBER:
345002828
ADMINISTRATOR:HEYDON, ANITAFACILITY TYPE:
740
ADDRESS:6729 SUGAR MAPLE WAYTELEPHONE:
(916) 200-8447
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 5CENSUS: 4DATE:
11/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Anita Heydon, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue post-licensing inspection. LPA met with administrator Anita Heydon during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA toured the facility and inspection 4 resident rooms, 2 bathrooms, garage area, backyard, kitchen and common living spaces. LPA observed the garage area, and saw it is only used as a storage area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility.
LPA reviewed 2 of 4 resident files and 2 staff record. LPA reviewed medications of 2 resident comparing with Centrally Stored Medication Record and physician orders. Resident files were found to be complete and current. LPA observed the following posted in each resident room: Resident Council Rights, See Something Say Something complaint poster, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

LPA observed the following deficiencies:

  • Administrator is pre-pouring medication over 24 hours in advance.
  • Administrator did not transfer caregiver fingerprints from sister facility to this facility.
Deficiencies cited on 809-D.

Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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 11/18/2021 02:16 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 11/18/2021 at 01:59 PM
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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUNRISE SENIOR CARE
FACILITY NUMBER: 345002828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of [total 2 caregivers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2021
Plan of Correction
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Administrator to send into CCL a copy of the LIC9182, LIC508, and copy of caregivers ID for a transfer request. In addition administrator agrees request a username for Guardian. administrator to send into LPA a copy of the fax confirmation or email that was sent into CCL for transfer request by 11/19/21.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in pre-pouring medications over 24 hours in advance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2021
Plan of Correction
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Administrator agrees to send into CCL a plan of who and when resident medications will be dispensed. Plan to be sent into CCL by 11/24/21.
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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021


LIC809 (FAS) - (06/04)
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