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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004852
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:57:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20220608080255
FACILITY NAME:SUNRIVER SENIOR CARE, LLC.FACILITY NUMBER:
347004852
ADMINISTRATOR:DIZON, SUSIEFACILITY TYPE:
740
ADDRESS:11229 PECOS RIVER COURTTELEPHONE:
(916) 853-1925
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 6DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Suzie DizonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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1) Resident’s diapering needs are not being met while in care.
2) Staff did not make sure resident had enough oxygen in his oxygen tank for his appointment
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Sunriver Senior Care, LLC (RCFE) on 9/22/22 at 1:15pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated because LPA Gould obtained statements from staff, residents and reporting party to confirm that the resident was placed in adult diapers that were either intended for an individual of the opposite sex or were sized too small for the resident. LPA was also able to corroborate that stall allowed resident to depart for a hospital appointment with an oxygen tank that did not have enough oxygen to meet the needs of the resident for the entire outing and a staff member had to meet resident a the hospital to provide another oxygen tank.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights and Medication are substantiated but if any additional information is received this complaint can be amended and the finding can be changed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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 5
Control Number 27-AS-20220608080255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SUNRIVER SENIOR CARE, LLC.
FACILITY NUMBER: 347004852
VISIT DATE: 09/22/2022
NARRATIVE
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The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220608080255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRIVER SENIOR CARE, LLC.
FACILITY NUMBER: 347004852
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care:The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by Statements obtained from staff, family and reporting party that the facility did not provide an oxygen tank
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Facility has agreed to and has already obtained an additional suppy of travel tanks that the facility agreed to inventory bi-weekly to ensure there is always an oxygen tank available to meet the residents needs for an outing or appointment. inventory to begin 9/26/22
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 with enough oxygen to last the resident's doctor appointment and a staff member had to bring another oxygen tank to the hospial to resident while away from the facility which poses an immediate health safety and peronal rights rick to resident in care.
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Type B
09/26/2022
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by statements obtained from staff, residents and reporting party corroborating allegations resident was placed in briefs intended for a member of the opposite sex and
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Facility has agreed to and has already obtained additional suppies for residents and will conduct bi-weekly inventory of diaper supplues for all residents to ensure the supplies meet the needs of the residents in care. inventory to begin 9/26/22
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or was a size too small which poses a potential health, safety or personal rights 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20220608080255

FACILITY NAME:SUNRIVER SENIOR CARE, LLC.FACILITY NUMBER:
347004852
ADMINISTRATOR:DIZON, SUSIEFACILITY TYPE:
740
ADDRESS:11229 PECOS RIVER COURTTELEPHONE:
(916) 853-1925
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 6DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Suzie DizonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident’s medication is being mismanaged
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Sunriver Senior Care, LLC (RCFE) on 9/22/22 at 1:15pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained and documentation reviewed during the investigation process, the allegations cannot be substantiated because LPA reviewed medication administration records and reviewed medications prescribed and physican orders for R1 (see confidential name list LIC-811 dated 9/22/22) which releaveld no errors and all medications were filled and adminstered to the resident in a timely manner and according to physicians instructions. LPA reviewed facility centally stocked PRN medications and observed no deficiencies. As the reporting party could not identify the medication administered or who the alleged medication may have previously belonged to, LPA could not corroborate this allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220608080255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SUNRIVER SENIOR CARE, LLC.
FACILITY NUMBER: 347004852
VISIT DATE: 09/22/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Medication are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5