Inspection Report Summary
Most inspections at this facility found no deficiencies, including the annual inspection on July 25, 2025, which was clean. Several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, some substantiated complaints involved medication management issues, such as administering medication without a physician’s order and staff not completing required medication training, as noted in the most recent September 24, 2025, report. Other deficiencies over time included personal rights violations related to visitation restrictions and failures in incident reporting and resident care assistance, but these were isolated and did not result in fines or enforcement actions. The facility’s record shows some improvement, with the latest annual inspection clean and no new enforcement actions reported.
Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 39
Capacity: 66
Deficiencies: 3
Sep 24, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff administered medication to a resident without a physician's prescription order and that staff did not complete required training.
Findings
The investigation substantiated that the facility assisted a resident with self-administered medication without a physician's order and that the Executive Director did not have current medication management training as required by the facility's Plan of Operation.
Complaint Details
Complaint investigation was substantiated based on evidence that staff administered medication without a physician's order and that required medication training was not completed by staff.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility assisted resident with self-administered medication without a physician’s order, posing immediate health, safety, and personal rights risk. | Type A |
| Facility did not ensure staff administering medications received training in accordance with the Plan of Operation, posing potential health, safety, and personal rights risk. | Type B |
| Facility failed to ensure staff assisting residents with self-administration of medication completed required 24 hours of initial training including hands-on shadowing and instruction. | Type B |
Report Facts
Facility capacity: 66
Census: 39
Plan of Correction due date: Sep 25, 2025
Plan of Correction due date: Oct 8, 2025
Medication training hours required: 24
Hands-on shadowing hours: 16
Other training hours: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation report |
| Tania Langland | Administrator | Facility administrator named in the report |
| Jessica Sanders | Executive Director | Interviewed regarding medication administration and training; found not to have current medication training |
| Hazel Gober | Business Office Coordinator | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 40
Capacity: 66
Deficiencies: 0
Jul 25, 2025
Visit Reason
The inspection was a Required-1 Year unannounced visit conducted to ensure compliance with Title 22 regulations for Sunrise Assisted Living of Carmichael.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with properly maintained bedrooms, bathrooms, kitchen, medication storage, and safety equipment. No deficiencies were cited during this visit.
Report Facts
Bedrooms observed: 6
Bathrooms observed: 5
Food supply: 2
Food supply: 7
Resident files reviewed: 5
Staff files reviewed: 5
Hot water temperature: 113.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Executive Director | Met with Licensing Program Analyst during inspection. |
| Angela Hood | Licensing Program Analyst | Conducted the Required-1 Year Inspection. |
| Tania Langland | Administrator/Director | Facility Administrator/Director listed in report. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 66
Deficiencies: 0
Jul 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff did not address a resident's lice infestation.
Findings
The investigation found the allegation to be unfounded after interviews, observations, and documentation review showed that the resident received lice treatments, the room was cleaned and treated, and no active lice or pests were observed during follow-up visits. No deficiencies were cited.
Complaint Details
The complaint alleged that staff did not address a resident's lice infestation. The investigation included interviews with staff and review of progress notes and treatment records. The allegation was found to be unfounded.
Report Facts
Capacity: 66
Census: 40
Dates of lice treatments: 3
Inspection start time: 1430
Inspection end time: 1700
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jessica Sanders | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Tania Langland | Administrator | Facility administrator named in report header |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 66
Deficiencies: 0
Mar 20, 2025
Visit Reason
The visit was conducted as a follow-up on a reported incident (SOC341) received on March 12, 2025, regarding an allegation of abuse involving a resident on March 6, 2025.
Findings
The facility conducted an internal investigation which found discrepancies in staff statements and no corroboration of the abuse allegation. A skin check revealed only minor bruising related to a blood draw. The allegation was unsubstantiated, and no citations were issued during the visit.
Complaint Details
The complaint involved an allegation by staff (S2) that staff (S1) forcefully grabbed a resident's arms. The facility's internal investigation and interviews did not substantiate the allegation. Staff (S1) was placed on leave pending investigation and will be reinstated on March 23, 2025.
Report Facts
Date of incident: Mar 6, 2025
Date SOC341 received: Mar 12, 2025
Date internal investigation completed: Mar 14, 2025
Date of visit: Mar 20, 2025
Number of residents in census: 40
Facility capacity: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janelle Odishoo | Senior Executive Director | Met with Licensing Program Analyst during visit and involved in investigation |
| Angela Hood | Licensing Program Analyst | Conducted the follow-up inspection and investigation |
Inspection Report
Annual Inspection
Census: 45
Capacity: 66
Deficiencies: 0
May 23, 2024
Visit Reason
The inspection was conducted as a Required-1 Year Inspection to ensure compliance with Title 22 regulations at Sunrise Assisted Living of Carmichael.
Findings
The facility was found to be in compliance with regulations, with properly furnished apartments, sanitary bathrooms, safe food storage, and no safety hazards observed. No deficiencies were cited during this visit.
Report Facts
Food supply: 2
Food supply: 7
Bedrooms observed: 5
Bedrooms observed: 3
Bathrooms observed: 5
Hot water temperature: 114.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Doreen Ntale | Resident Care Director | Met with Licensing Program Analyst during inspection |
| Angela Hood | Licensing Program Analyst | Conducted the inspection |
| Tania Langland | Administrator | Facility Administrator named in report header |
Inspection Report
Annual Inspection
Census: 45
Capacity: 66
Deficiencies: 0
May 17, 2024
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations.
Findings
No deficiencies were cited during this inspection per California Code of Regulations, Title 22. The Licensing Program Analyst reviewed five resident files and five staff files and will return later to complete the annual inspection.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Doreen Ntale | Resident Care Director | Met with Licensing Program Analyst during inspection |
| Angela Hood | Licensing Program Analyst | Conducted the Required-1 Year Inspection |
| Tania Langland | Administrator | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 66
Deficiencies: 0
May 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-01-19 regarding resident care concerns at Sunrise Assisted Living of Carmichael.
Findings
The investigation included interviews, observations, and documentation review related to allegations about resident hygiene, phone call privacy, food sufficiency, and dental care. The findings concluded that although the allegations may have occurred, there was insufficient evidence to substantiate violations, and no deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not ensuring resident hygiene needs, restricting private phone calls, insufficient food provision, and unmet dental needs. Interviews and documentation showed care was provided appropriately, and the resident appeared well groomed, able to make and receive calls, received sufficient food, and had access to dental services.
Report Facts
Capacity: 66
Census: 45
Complaint Control Number: 59-AS-20240119121758
Inspection start time: 02:20 PM
Inspection end time: 05:15 PM
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Abby Johnson | Terrace Club Coordinator | Met with Licensing Program Analyst during investigation |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 66
Deficiencies: 0
Jan 24, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of staff emotionally abusing a resident in care.
Findings
Interviews with residents and staff indicated no evidence of emotional abuse by staff towards residents. The allegation was found to be unsubstantiated and no deficiencies were cited during the visit.
Complaint Details
The complaint alleged emotional abuse of a resident by staff. After investigation, including interviews with residents and staff, there was insufficient evidence to substantiate the allegation. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 66
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Andy Pardede | Resident Care Director | Met with Licensing Program Analyst during the investigation |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 66
Deficiencies: 1
Dec 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/30/2023 regarding medication administration and staff qualifications at Sunrise Assisted Living of Carmichael.
Findings
The investigation substantiated that staff did not give residents' medication as prescribed, with medication counts showing discrepancies for residents R1, R2, and R3. Another allegation that unqualified staff dispensed medication was unsubstantiated based on interviews and documentation. A deficiency was cited related to medication management.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not give residents' medication as prescribed. The allegation that unqualified staff dispensed medication was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure that residents (R1, R2, & R3) were receiving medications as prescribed, posing an immediate health, safety, and personal rights risk. | Type A |
Report Facts
Capacity: 66
Census: 50
Number of nurses: 5
Number of Med Techs: 2
Deficiency count: 1
Plan of Correction due date: Dec 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Barbara Barron | Senior Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Tania Langland | Administrator / Executive Director | Provided interview regarding staff qualifications and medication administration |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 66
Deficiencies: 1
Dec 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including staff violating a resident's personal rights and lack of care and supervision leading to resident hospitalization.
Findings
The investigation substantiated that staff violated a resident's personal rights by restricting visitation without legal authority. The allegation regarding lack of care and supervision leading to hospitalization was found unsubstantiated due to insufficient evidence. A deficiency related to personal rights visitation was cited.
Complaint Details
The complaint investigation was substantiated for the allegation that staff violated a resident's personal rights by restricting visitation without a court order or police restraining order. The allegation that staff lack of care and supervision led to resident hospitalization was unsubstantiated due to lack of sufficient evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights of Residents in All Facilities (a)(11) - To have their visitors permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. | Type B |
Report Facts
Capacity: 66
Census: 51
Plan of Correction Due Date: Jan 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Barbara Barron | Senior Executive Director / Interim Administrator | Met with Licensing Program Analyst during investigation and report delivery |
| Tania Langland | Administrator | Facility administrator named in report header |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 52
Capacity: 66
Deficiencies: 0
Jul 6, 2023
Visit Reason
The inspection was an unannounced annual/random visit conducted to perform a Required-1 Year Inspection using the CARE inspection tool to ensure compliance with health and safety regulations.
Findings
The facility was found to be clean, safe, sanitary, and in good condition with no immediate health, safety, or personal rights violations observed. Resident and staff files were complete and current, and the facility had appropriate staff and supplies to meet resident needs. No deficiencies were noted as a result of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tania Langland | Administrator | Met with Licensing Program Analyst during inspection and reviewed report. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Maribeth Senty | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 1
Jun 16, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-02-17 regarding staff not assisting a resident with hearing aids and other care-related allegations.
Findings
The investigation substantiated that staff failed to assist resident R1 with weekly hearing aid battery replacement, posing a potential health and safety risk. Other allegations related to physician's orders, housekeeping, personal belongings, showering, clean linen, and facility hazards were found unsubstantiated.
Complaint Details
The complaint was substantiated regarding failure to assist resident with hearing aids. Other allegations were unsubstantiated. The substantiated allegation means the complaint was valid based on the preponderance of evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist resident with hearing aid battery replacement as required, posing a potential risk to the resident. | Type B |
Report Facts
Capacity: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Tania Langland | Director/Administrator | Met with Licensing Program Analyst during investigation and received report |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 0
Jun 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-03-07 regarding staff sexual and physical abuse and refusal to seek medical attention for a resident.
Findings
The investigation found the complaint to be unfounded after reviewing staff, facility, hospital, and police records and conducting interviews. The facility met Title 22 requirements, and no signs of injury or abuse were found on the resident.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or lacked a reasonable basis. The resident was unable to state concerns, and the department dismissed the complaint.
Report Facts
Facility capacity: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
| Davina Barker | Administrator | Facility Administrator met during investigation |
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 2
Jun 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-28 regarding a resident sustaining unexplained injuries while in care.
Findings
The investigation found that an altercation occurred between two residents on 2023-03-12, during which caregivers were initially not present but responded after hearing yelling. One resident was hit in the shoulder, and subsequent bruising and swelling were observed. The facility failed to notify responsible parties and submit a required report to licensing, constituting a substantiated complaint and a potential health and safety risk.
Complaint Details
The complaint was substantiated. The allegation that a resident sustained unexplained injuries while in care was found valid based on evidence. The incident involved an altercation between two residents, with inadequate staff presence and failure to report the incident as required.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency and responsible parties within seven days of the occurrence as required. | Type B |
| Failure to report an incident which threatened the welfare, safety, or health of residents, posing a potential risk to residents. | Type B |
Report Facts
Facility capacity: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Tania Langland | Administrator | Facility administrator met with Licensing Program Analyst during investigation and was involved in report review |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 66
Deficiencies: 0
Oct 18, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 08/01/2022 regarding staff hitting a resident and handling a resident in a rough manner.
Findings
The investigation included interviews with staff, the resident, family members, and review of resident records. The allegations were found to be unfounded, meaning they were false or without reasonable basis.
Complaint Details
The complaint involved allegations that staff hit a resident and handled the resident roughly. After interviews and record reviews, the allegations were determined to be unfounded.
Report Facts
Capacity: 66
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Christina Bond | Health Care Director | Met with the Licensing Program Analyst during the investigation |
| Davina Barker | Administrator | Facility administrator named in the report |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 66
Deficiencies: 0
Aug 30, 2022
Visit Reason
The visit was an unannounced case management inspection regarding a serious injury incident report submitted to the Department on 2022-08-23 involving a resident fall on 2022-08-19.
Findings
The Licensing Program Analyst conducted interviews, reviewed relevant documents including the resident's profile and hospital reports, and found no deficiencies during the inspection.
Complaint Details
The complaint involved a serious injury incident where a resident fell while attempting to self-transfer to the bathroom, was found on the floor in severe pain, and was transported to UC Davis Medical Center. The resident was discharged and returned to the community the same day. The investigation found no deficiencies.
Report Facts
Facility capacity: 66
Resident census: 41
Inspection start time: 1330
Inspection end time: 1600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lyndee Whaley | Executive Director | Met with Licensing Program Analyst during inspection |
| Rachel West | Terrence Club Coordinator | Met with Licensing Program Analyst during inspection |
| Christina Bond | Resident Care Director | Met with Licensing Program Analyst during inspection |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Annual Inspection
Census: 39
Capacity: 66
Deficiencies: 0
Jul 22, 2022
Visit Reason
The inspection was an unannounced required annual visit conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.
Findings
The facility was observed to be clean, safe, and in good repair with no health or safety risks or personal rights violations. PPE supplies and emergency provisions were adequate, and all staff were observed wearing masks. No deficiencies were found during the inspection.
Report Facts
Hospice waiver residents: 5
Hospice waiver capacity: 15
Emergency water supply: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the inspection and authored the report |
| Cynthia Bazin | Executive Director | Met with Licensing Program Analyst during inspection |
| Amir | Maintenance Coordinator | Joined the inspection tour |
Inspection Report
Census: 43
Capacity: 66
Deficiencies: 0
Apr 21, 2022
Visit Reason
The inspection was an unannounced Case Management visit conducted to follow-up on incident reports received by the department.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst reviewed incident reports involving resident falls, pressure injury, and GI bleed, and found that necessary care and supervision were provided, with recommendations for improved documentation and prompt notification of condition changes.
Report Facts
Capacity: 66
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and authored the report |
| Davina Barker | Administrator | Met with the Licensing Program Analyst during the inspection |
| Maribeth Senty | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 2
Apr 21, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to complaints received on 2022-01-05 regarding resident pressure injuries, blocked emergency exits, and retention of a resident needing a higher level of care.
Findings
The investigation substantiated that a resident sustained Stage III pressure injuries while in care and was retained at the facility, which is a prohibited condition posing an immediate health risk. Additionally, emergency exits were found blocked on multiple occasions, posing a potential health and safety risk to residents.
Complaint Details
Complaint investigation was substantiated based on evidence including resident records, interviews, and photographs. The resident sustained pressure injuries while in care, and emergency exits were blocked. The allegation that the facility retained a resident needing a higher level of care was also substantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Retaining a resident with Stage III pressure injuries, a prohibited health condition. | Type A |
| Blocked emergency exits on at least three occasions. | Type B |
Report Facts
Capacity: 66
Census: 43
Deficiencies cited: 2
Plan of Correction Due Dates: Apr 25, 2022
Plan of Correction Due Dates: May 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Davina Barker | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 0
Apr 13, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations of staff physically assaulting a resident and failing to properly report the incident to the responsible party.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident had a physical altercation with a staff member resulting in a fall and injury, but the department was unable to find a preponderance of evidence that the alleged violations occurred.
Complaint Details
The complaint involved allegations that staff physically assaulted a resident and did not properly report the incident. The investigation included interviews and records review. The resident had dementia and a history of aggression. Staff and family were interviewed, but the evidence was insufficient to substantiate the complaint. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 66
Census: 43
Incident date: Sep 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Davina Barker | Administrator | Facility administrator met during the investigation and participated in exit interview |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 66
Deficiencies: 4
Aug 4, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including failure to report resident's change in condition, failure to seek timely medical attention, injury due to an unwitnessed fall, admission without responsible party's consent, and moving a resident without consent.
Findings
The investigation substantiated several allegations including failure to notify the conservator of a resident's positive UTI lab results, delayed medical care for UTI, admission without conservator's written consent, and moving a resident without providing the required 30-day written notice to the conservator. One allegation regarding failure to observe a resident's change in condition was unsubstantiated, and another regarding inadequate incontinent care was found to be unfounded.
Complaint Details
The complaint investigation was substantiated based on evidence that the facility failed to timely notify the conservator of a resident's positive UTI lab results, delayed medical care, admitted a resident without conservator's written consent, and moved a resident without proper notice. One allegation about failure to observe a resident's change in condition was unsubstantiated, and another about inadequate incontinent care was unfounded.
Severity Breakdown
Type A: 1
Type B: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility did not ensure timely medical care for UTI, posing immediate health, safety, and personal rights risk. | Type A |
| Facility failed to notify conservator of resident's change in condition, posing potential health, safety, and personal rights risk. | Type B |
| Facility did not obtain conservator's written consent for admission of resident. | Type B |
| Facility failed to provide 30-day written notice to conservator for resident's room change. | Type B |
Report Facts
Facility capacity: 66
Resident census: 40
Plan of Correction due date: Aug 5, 2021
Plan of Correction due date: Aug 18, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Davina Barker | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Josef Dunham | Administrator | Named as facility administrator in report |
Inspection Report
Annual Inspection
Census: 41
Capacity: 66
Deficiencies: 0
Jul 20, 2021
Visit Reason
The inspection was an unannounced required 1-year annual inspection focusing on the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with infection control requirements, with no immediate health, safety, or personal rights violations observed and no deficiencies cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Praveen Singh | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Davina Barker | Executive Director | Met with the Licensing Program Analyst during the inspection. |
| Josef Dunham | Administrator | Named as facility administrator. |
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