Sunrise Assisted Living of Fair Oaks

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Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the care home unannounced on March 24, 2026 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed eight (8) apartments in Assisted Living, seven (7) apartments in Memory Care, and three (3) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 115 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on site. LPA observed the perimeter of the care home to be free of clutter and debris. LPA ensured that delayed egress in Memory Care was operational. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers are maintained and ready for emergency use. LPA reviewed five (5) resident files and five (5) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy. LPA also requested copies of the facility's emergency disaster plan and staff roster during visit. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to review medications and finish inspection of the care home. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Lydia Gravelyn, to conduct a case management visit to follow-up regarding incident reports received by the department on December 16, 2025 and December 18, 2025 for resident (R1). During visit, LPA reviewed records for R1 and requested copies of pertinent documents. LPA will conduct a follow-up visit if deemed necessary. No deficiencies are being cited as a result of today's visit. Exit interview was conducted with ED. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 13, 2026

Allegation investigated: Staff mismanage medication.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Lydia Gravelyn, to deliver investigation findings into the complaint allegation listed above. During the course of the investigation, LPA conducted interviews, conducted a medication count, and review documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Staff mismanage medication. ** Report continued on 9099-C ** Substantiated During visit conducted on April 22, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing the residents’ Centrally Stored Medication Forms (CSM) with medications centrally stored for the residents. LPA observed one (1) medication for R1 to be over the amount documented in R1's CSM. Facility was unable to provide any documentation to explain why R1's medication was over the amount documented. LPA observed Medication Administration Record (MAR) for R1, which indicated that medication was administered every day since start date documented and no tabs were missed. LPA observed one (1) medication for R3 to be over the amount documented in R3's CSM. Facility was unable to provide any documentation to explain why R3's medication was over the amount documented. LPA observed MAR for R3, which indicated that medication was administered every day since start date documented and no tabs were missed. LPA observed CSMs for R3's medication dating back to November 2024 and observed that R3's medication had gaps of several days between each refill. Facility was unable to provide documentation to explain the gaps of several days in which R3 was not provided medication between each refill. Based on a medication count, observation, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $250 is assessed for April 23, 2025 for a repeat violation within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents. Interviews with staff members S1, S2, S3, and residents R4, R5, R6, and R7 indicated that they have never observed the facility to be malodorous. Interview with ED indicated that, since starting at the facility, they have never observed the facility to be malodorous. During visits conducted on April 22, 2025 and April 23, 2025, LPA toured the premises, including the Memory Care Unit (MCU), and did not observe facility to be malodorous. Allegation: Staff does not ensure facility is clean. Interviews with S1, S2, S3, R4, R5, R6, and R7 indicated that they have never observed the facility to be unclean. Interviews with S1, S2, and S3 indicated that the facility does a good job with providing incontinence care to residents and ensuring facility is clean in case of an accident. Interview with ED indicated that, since starting at the facility, they have never observed the facility to be unclean. During visits conducted on April 22, 2025 and April 23, 2025, LPA toured the premises, including the MCU, and did not observe facility to be unclean. Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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. Exit interview was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 59-AS-20250418122601

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 24, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and records reviewed, the facility did not ensure that residents R1 and R3 received medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2025

Plan of correction: Facility will complete an inservice with staff regarding medication administration. Facility will also continue weekly medication audits. Facility will submit to LPA information regarding in-service training and medication audit, including time and date of in-service and training material, by POC due date. A civil penalty of $250 is assessed for a repeated violation.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 3/26/25 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed five (5) apartments in Assisted Living, four (4) apartments in Memory Care, and three (3) common area bathrooms. LPA conducted interviews with four (4) residents and three (3) staff during inspection. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 116.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed the perimeter of the care home to be free of clutter and debris. LPA ensured that delayed egress in Memory Care was operational. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers are maintained and ready for emergency use. First aid kit is maintained and ready for emergency use. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed two (2) residents' medications, five (5) resident files and three (3) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of today's visit, a deficiency is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on the attached 809-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 26, 2025

Allegation investigated: Staff does not respond to resident's call for assistance in a timely manner

Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Senior Executive Director (SED), Cortez Jordan, to deliver findings regarding the complaint allegation listed above. During the investigation, LPAs conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Staff does not respond to resident's call for assistance in a timely manner ** Report continued on 9099-C ** Substantiated Interviews with residents R1, R2, R3, R4, and relevant party indicated that the facility does not have sufficient staff to meet the residents' care needs. R1 stated that they've had to wait about an hour for a response from care staff with their call button. R1 stated that there are too many residents in need for staff to care for and they don't get enough time to care for the residents. R2 stated that there are a lot of residents in need of assistance and some caregivers are pulling two wheelchairs at the same time. R2 stated that caregivers cannot spend enough time with residents because there are too many residents in need of assistance for the amount of caregivers on shift. R3 stated response times to call buttons are never ten (10) minutes and they've had to wait an hour for assistance after sustaining a fall. R4 stated that management reduced the amount of staff on duty at any given time and has had to wait an hour for a response to their call button. Interview with relevant party indicated that caregivers don't even have enough time to talk with residents and are stretched thin. Relevant party stated that staff want to provide care to residents, but just can't due to there not being enough staff on duty. Interviews with staff members S1, S3, and S4 indicated that standard response times to resident call buttons should be within ten (10) minutes. Interview with S1 indicated that R1 has had to wait forty-five (45) minutes to receive assistance to the dining room due to S1 needing to provide care to other residents. Interview with staff member (S2) indicated that they can take fifteen (15) to twenty-five (25) minutes to respond to a call button. S2 stated that there are a lot of residents who need assistance from staff and they can't "do everything at once." S2 stated that they may not have time to respond to a call button due to providing care to someone else. S2 stated that they feel staffing is "terrible" at the facility. Interview with S3 indicated that staff get busy and can't assist residents timely. S3 stated that they feel the facility is short on staffing. Interview with S4 indicated that "everything" is not being responded to timely and they "definitely" feel there should be more staff on duty. ** Report continued on 9099-C ** LPAs obtained and observed facility's Emergency Needs Response, which states "response call logs are reviewed at community morning meetings and monthly Quality Assurance meetings. All calls exceeding a 10 minute time response will be reviewed further." LPAs observed call button logs for resident R1, R2, R3, R4, R5, R6, R7, R8, and R9 for the month of September 2024. LPA observed multiple call button response times exceeding 10 minutes and reaching as long as 419 minutes. LPAs toured the facility and observed that it took 12 minutes to walk the interior and exterior parameter of the care home. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 16, 2024 · control 59-AS-20241003174020

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 31, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based interviews conducted and records reviewed, the facility did not ensure call buttons for residents were responded to in a timely manner, resulting in response times reaching as long as 419 minutes, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Facility will develop a plan to address staffing and submit plan to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Senior Executive Director (SED), Cortez Jordan, to issue a citation in relation to a separate inspection. During inspection conducted on 10/16/2024, it was observed that resident (R1) sustained multiple falls at the facility. Two of the falls resulted in injury according to Post Fall Evaluations provided. LPAs requested Unusual Incident Reports (SIRs) for R1's falls. Facility could not produce and supply LPAs with requested SIRs during visit. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D page regarding reporting requirements. Exit interview was conducted with SED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 31, 2024

87211 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 of the occurrence of any of the events specified in (A) through (D) below. (...) This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to report multiple falls for R1 to the licensing agency, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Facility will complete a statement of understanding regarding regulation 87211. Facility will submit statement to LPA by POC due date of 10/31/24.

Allegation investigated: Staff mismanaged resident medication

Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Executive Director (ED), Jonathon Moore, to open a complaint investigation into the allegation listed above. During today's visit, LPAs conducted interviews and review documentation pertinent to the investigation. Relevant party reported that resident (R1) received a medication via mailed cold box that went missing. It was reported that package was confirmed to be delivered. It was also discovered on 9/19/2024 that a staff member (S1) received the package and brought the package directly to R1 to be stored in their personal refrigerator. ** Report continued on 9099-C ** Substantiated Interview with ED indicated that an injectable medication for R1 was received by the facility on 9/12/2024 and S1 brought the package in which medication was stored directly to R1 and placed contents in R1's refrigerator. ED stated that it was believed that R1 self-administered the injectable medication. Interview with S1 indicated that they received a package for R1 while working at the front desk and observed that package needed to be refrigerated immediately. S1 stated that they noticed the name on the package and took the package to R1's room right away. S1 stated that they opened the package with R1 and had R1 stored contents of package in their refrigerator. LPAs received a Special Incident Report (SIR) regarding the incident date 9/19/2024. SIR states "Resident had medication delivered on 9/12/2024. Medication was not located in the community. On 9/19/2024 it was discovered that an employee had taken the medication directly to the resident, who then self-administered. Resident observed and monitored, determined to be ok." LPAs reviewed R1's Physician's Report LIC 602A dated 3/18/2024, which states R1 is not able to administer own prescription medications but is able to administer own injections with assistance and observation. LIC 602A also states that R1 is not able to store own medications. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 59-AS-20240920133852

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 26, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and records reviewed, the facility did not ensure that resident R1 received assistance with medication administration in accordance with their Physician's Report, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Facility will complete an inservice with staff regarding medication administration. Facility will submit to LPA information regarding in-service training by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 26, 2024

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on interviews and records reviewed, the facility did not ensure that R1's medication was centrally stored in a safe and locked place, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Facility will complete an inservice with staff regarding centrally storing medication. Facility will submit to LPA information regarding in-service training by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 1/31/24 to conduct an annual continuation visit utilizing the inspection tool following the Required-1 Year Inspection conducted on 1/25/2024. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. First aid kit is maintained and ready for emergency use. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and three (3) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Jan 31, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 1/25/24 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) apartments in Assisted Living, two (2) apartments in Memory Care, and three (3) common area bathrooms. LPA conducted interviews with four (4) residents and four (4) staff during inspection. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 116.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed the outdoor area for Assisted Living and Memory Care to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. LPA observed the perimeter of the care home to be free of clutter and debris. LPA ensured that delayed egress in Memory Care was operational. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers are maintained and ready for emergency use. LPA reviewed three (3) staff files during visit. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to finish reviewing files and complete annual inspection. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Jan 25, 2024