Sundial Assisted Living

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Non-qualified staff provided wound care.

On 06/17/2026, Marisa Chiarelli, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 05/22/2026. LPA Chiarelli met with resident services director Sherril Denny and explained the purpose of the visit. During the interview process, three persons were interviewed. The following documents were received and reviewed: Resident hospice/care notes, and incident reports and photographs of the wounds were shown LPA Chiarelli upon initial visit to the facility by a hospice nurse. Continued on 9099 - C Substantiated On 5/22/26 LPA Chiarelli received an incident report, the incident reported an incident that happened with (resident one) R1 on 5/21/26. The incident was that a caregiver (C1) at the facility provided wound care to a resident when a blister was popped which created a larger wound by a caregiver (C1) at the facility. R1 is currently receiving wound care from hospice. During the investigation two hospice nurses were interviewed. While reviewing the incident report it gives a statement from the staff member (C1) who was involved in the incident their statement stated: “She said she was aware that she was not supposed to pop it but that she thought she was helping him and that she would never do it again and she was so sorry.” When LPA Chiarelli inferred about the statement to C1s supervisor they stated that statement was what C1 told them. Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 59-AS-20260522155905

From the deficiency page — Deficiency type: Type A · Section cited: CCR 887631(a)(1) · Plan of correction due date: Jun 19, 2026

87631(a)(1) Healing Wound (a) Except as specified in Section 87611...the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances...When care is performed by or under the supervision of an appropriately skilled professional. This requirement is not met as evidenced by: Based on record review, incident reports and interviews, an unqualified staff member provided wound care. Which poses a immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee will have all caregivers and med techs complete a training on wound care. Licensee will submit proof of correction to LPA by POC due date.

Allegation investigated: Unqualified staff providing care to residents

On 04/23/2026, Marisa Chiarelli, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 03/30/2026. LPA Chiarelli met with Elizabeth Amlin and explained the purpose of the visit. During the investigation 4 staff were interviewed, and staff records were reviewed. Complaint alleges that unqualified staff providing care to residents. Based on interviews and staff record reviewed, LPA could not prove or disprove the allegation. Through staff record review LPA Chiarelli was able to find that all dietary staff had all training which is required under title 22 regulations. Unsubstantiated Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Exit interview conducted and copy report given to administrator.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 59-AS-20260330110221

Type of visit: Case Management - Health Checks

Licensing Program Analyst K. Hiratsuka, conducted this unannounced case management visit. This visit is a health and safety check in response to four residents who were relocated to this facility yesterday from another facility. LPA spoke to the two residents. LPA did not observe any deficiencies. No deficiencies cited.the state’s words, verbatim · CDSS document, Mar 18, 2026

Allegation investigated: Staff do not ensure there is a written record of dietitian consultation visits. Staff did not address residents change in condition.

On 1-15-26, Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 09/09/25. LPA Benson met with Administrator Elizabeth Amlin, and explained the purpose of the visit. During the interview process interviews were completed and records were reviewed. The following documents were received and reviewed: staff list with telephone numbers and work schedule, resident roster, care plans, end of shift notes for resident, weight records, written record of nutritionist/dietitian consult, daily assignment sheets and incident reports. Continued on LIC9099C & LIC9099D Substantiated Staff do not ensure there is a written record of dietitian consultation visits. Document review revealed that the facilities last recorded dietitian consultation was dated 2018. During interviews the Administrator reported for years the facility has had no nutritionist, dietitian or economist for consultation. Staff did not address residents change in condition Document review revealed, on 7-30-23 the resident weighed 229 lbs. Record review revealed a hospital visit on 1-8-25 with a recorded weight of 178 lbs. Record review reported a reappraisal completed on 2-21-25 with a recorded weight of 174.3 lbs. Record review revealed a reappraisal completed 9-9-25 with recorded weight of 140 lbs. Record review found no reappraisal completed from 7-30-23 to 2-21-25. The reappraisal report dated 9-9-25 stated the resident is experiencing nutritional problems. The report stated snack monitoring daily and daily documentation of food intake of meals. Document review revealed that the resident is diabetic with carbohydrate intake control. Document review states the resident is independent for dining with occasional reminders of mealtimes. The report states that staff will order a room tray if resident did not want to come to dining area. It was reported staff contacted a family member on 9-2-25 with concerns of the residents’ weight loss. It was reported that the facility recommended hospice as an intervention for severe weight loss. It was reported the family didn’t agree and contacted the resident’s physician. It was observed the facility completed a change in condition report on 9-9-25. Record review revealed the resident had severe weight loss as evidenced by a weight loss from 7-30-23 weight 229 lbs. to reappraisal on 2-21-25 weight of 174.3 lbs. Record review revealed the reappraisal did not address the weight loss. Record review revealed the next reappraisal completed 9-9-25 revealed further weight loss with recorded weight of 140 lbs. It was reported that the resident revealed significant fat and muscle waste. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals un-met needs.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 59-AS-20250909090827

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(17) · Plan of correction due date: Jan 15, 2026

General Food Service Requirements The following food service ... (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training ... If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency... This requirement is not met as evidenced by: Based on documentation reviewed, the facility did not ensure the facility had a nutritionist with written records. Which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The Administrator hired a dietitian that will perform the concultations and written records.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Feb 15, 2026

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: The licesenee did not address the residents weight loss. Which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator will have a training with staff concerning reporting requirement of observation of the residents. Administrator will send a copy of the training with staff signatures to LPA. Administrator will weigh the residents on a regular basis.

Type of visit: Case Management - Incident

On 1-15-26 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to perform a case management concerning complaint 59-AS-20250909090827. LPA met with Administrator Elizabeth Amlin. During the complaint investigation it was discovered a residents reappraisal was not completed as necessary. See attached 809D Residents reappraisal was not completed as necessary. Record review revealed the resident had severe weight loss as evidenced by a weight loss from 7-30-23 weight 229 lbs. to reappraisal on 2-21-25 weight of 174.3 lbs. Record review revealed the reappraisal did not address the weight loss. Record review revealed the next reappraisal completed 9-9-25 revealed further weight loss with recorded weight of 140 lbs. It was reported that the resident revealed significant fat and muscle waste. See attached 809Dthe state’s words, verbatim · CDSS document, Jan 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(f) · Plan of correction due date: Feb 16, 2026

Reappraisals (f) The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record. This requirement is not met as evidenced by: Based on documentation reviewed the facility did not perform a reappraisal when the resident had weight loss. Which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Tha administrator will complete a reappraisal training with staff. The administrator will notify LPA when complete.

Allegation investigated: Staff are not giving residents a shower.

On 12-09-25, Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 07/31/25. LPA Benson met with Resident Services Director Sherril Denny, and explained the purpose of the visit. During the interview process, four staff persons and two residents were interviewed. The following documents were received and reviewed: staff list with telephone numbers and work schedule, resident roster, care plans, end of shift notes, shower logs, daily assignment sheets and incident reports. Continued on LIC9099C & LIC9099D Substantiated Staff are not giving residents a shower. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. According R1's Individualized Assessment Form R1 should receive assistance with bathing 2 times per week. Upon review of the services received in August 2025, R1 received bathing assistance once during the first week of August, which did not meet the 2 times per week agreement. During staff interviews staff reported a caregiver was assigned a new AM shift and didn’t realize R1s shower was due during the AM shift on 8-1-25. Further review discovered staff stated on 7-25-25 the activities director covered for an AM call out shift. Staff stated resident showers were missed on 7-25-25 and the PM shift should have given the missed residents showers. Staff stated whichever hall you are assigned to that staff is responsible for all of the resident’s care needs including showers. During the resident interviews a resident stated I have missed other showers but can’t remember the dates. It was determined staff are not giving residents showers as individualized assessments require. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. An exit interview was conducted. A copy of the report with appeal rights was provided to staff.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 59-AS-20250731125050

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 30, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on documentation reviewed, the facility did not ensure resident (R1) was receiving assistance with bathing as agreed in the Individualized Assessment, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Facility agrees to conduct an in-service training with staff ensuring they understand the importance of following the residents' individualized care plan. Facility agrees to submit a list of all participants with the date to LPA by the POC due dates.

Allegation investigated: Lack of staffing.

On 11-3-25, Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 06/17/25. LPA Benson met with Administrator Elizabeth Amlin and explained the purpose of the visit. During the interview process, three staff persons and two residents were interviewed. The following documents were received and reviewed: staff list with telephone numbers and work schedule, resident roster, care plans for two person assist residents, end of shift notes for all residents, Daily assignment sheets and incident reports. Substantiated It was alleged (ADLs) are not being completed for all residents, as resident R1 is requiring a great amount of care based on R1s time of a resident with a contagious medical confinement. . During staff interviews its was reported the residents’ care needs were compromised, a bed bath instead of a full shower, not spending the time necessary to get to the residents in a timely manner. Staff reported when we go to lunch the other care staff can’t get to all of the call buttons and the medication technician is passing out the meds. Staff reported the residents have complained, some understand that we are busy. During the resident interviews R2 stated it takes about five minutes and then they say the will be right back and that is fifteen more minutes. The resident reported, I don’t like being left on the toilet for a half hour. The resident stated it takes forever, sometimes a half hour when I need assistance to go to the bathroom or get off the pot. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Reulations, (Title 22), is cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 59-AS-20250617124218

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 10, 2025

87411(a) Personnel Requirements, General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on interviews and records the residents ADL’s were not completed during the time of a resident with a contagious medical confinement. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Nov 3, 2025

Plan of correction: Staff have had training for contagious medical confinement PPE. Staff have end of shift notes to record ADL's completed. Monitoring of call button response times. Sharing daily ADLs during shift change. Administrator will notify LPA of Call Button response times.

Type of visit: Required - 1 Year

On 11/03/2025 at 10:30am Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Elizabeth Amlin (cert #7020844740 exp: 11-21-27) and explained the purpose of the visit. Administrator certificate is current. LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to two (2) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet. The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, lighting and windows with screens. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the residents. All required postings are displayed within the facility. No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 10-30-25, the facility has been conducting drills every 3 months. LPA interviewed two resident and two staff. The facility is in compliance. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator.the state’s words, verbatim · CDSS document, Nov 3, 2025

Allegation investigated: Staff are not taking steps to prevent the spread of a communicable disease. Staff do not ensure staff are properly trained. Staff do not ensure facility has adequate Personal Protective Equipment (PPE) supplies.

On July 17, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/23/25. LPA Adkison met with Sherrill Denny, LVN and Michelle Decoito, Business Office Manager, and explained the purpose of the visit. Allegation: Staff are not taking steps to prevent the spread of a communicable disease. withSherrill During the interview process, the Administrator, Wellness Services Director and several staff persons were interviewed. Documents were obtained to include Physicians Reports, Emergency Information, Appraisals and Needs, Admission Agreements, hospital notes, staff person names and contact numbers. Continued on LIC 9099-C. Substantiated During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA), which is highly contagious. It was stated that Resident 1 was in the facility with MRSA during the month of April 2025. It was reported that Resident 2 was in the facility with MRSA during the month of June 2025. It was stated that initially, staff were not given the information or directive that residents had MRSA. Based on investigation observations, interviews, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Allegation: Staff do not ensure staff are properly trained. During the interview process, the Administrator, Wellness Services Director and several staff persons were interviewed. Documents were obtained to include Physicians Reports, Emergency Information, Appraisals and Needs, Admission Agreements, hospital notes, staff person names and contact numbers. During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). It was stated by several persons that the medication technicians and care providers were not provided with training regarding providing care and supervision with residents that have MRSA. It was reported that management gave a verbal instruction; however, no formal training. Training did not include documentation from an appropriately skilled professional stating what aspects of care will be delegated to facility staff responsible for the care and that the appropriately skilled professional will train those staff persons prior to delegating care. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Report Continued on additional LIC 9099-C Allegation: Staff do not ensure facility has adequate Personal Protective Equipment (PPE) supplies. During the interview process, the Administrator, Wellness Services Director, and several staff persons were interviewed. Documents were obtained to include Physicians Reports, Emergency Information, Appraisals and Needs, Admission Agreements, hospital notes, staff person names and contact numbers. During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). Staff were advised to use gloves; however, were not told of the importance to use Personal Protective Equipment (PPE) to include gloves, mask, gown and foot booties. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 59-AS-20250423134418

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 18, 2025

Personal Rights - In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure that all staff were aware that residents had Methicillin-Resistant Staphylococcus Aureus (MRSA), or other serious infection. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: POC – The administrator agrees to ensure that all staff providing care and supervision are aware that the residents have/had MRSA. The administrator shall submit to the licensing agency that she agrees with the regulation by end of business 07/18/2025 The administrator has since ensured that MRSA training was provided to all medication technicians and care providers. The administrator shall submit to the licensing agency a sign in sheet signed by the providers that they did receive training by end of business 07/18/2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 18, 2025

Personnel Requirements, General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not provide formal training to staff regarding Methicillin-Resistant Staphylococcus Aureus (MRSA). This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2)(A) · Plan of correction due date: Jul 18, 2025

87470(b)(2)(A) - Infection Control Requirements - In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents… This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure that staff were provided with all PPE supplies during a time when a resident had MRSA. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: The licensee/administrator shall ensure that PPE is always provided to staff. Licensee/administrator will put in writing to the licensing agency that she agrees with ensuring that PPE is always available to staff by end of business 07/18/2025.

Type of visit: Case Management - Deficiencies

A Case Management visit was conducted on July 17, 2025, by LPA Kayla Adkison, as during the investigation of complaint #59-AS-20250423134418, it was determined that the licensee/administrator did not request from the licensing agency an exception for two residents residing at the facility that had been diagmosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). Based on observations, interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report was provided to Sherrill Denny, LVN and Michelle Decoito, Business Office Managerthe state’s words, verbatim · CDSS document, Jul 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87616(a) · Plan of correction due date: Jul 18, 2025

87616(a) Exceptions for Health Condition - As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not follow the guidelines of the Prohibited Health Conditions. Licensee/administrator should have requested to have an exception in place. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: The licensee/administrator agrees to submit to the licensing agency an exception request for each resident in care that has or had MRSA. This POC has been corrected and cleared at the time of the visit on 07/17/2025.

Allegation investigated: Personal Rights-Residents have the right be accorded dignity in their personal relationships with staff. Food Service-Resident was not provided with the meal of their choice.

On February 24, 2025, at approximately 12:15 PM, Licensing Program Analysts (LPA), Farhaan Sarangi and Kayla Adkison arrived unannounced at Sundial Assisted Living for the purpose of delivering complaint findings. LPAs met with Residential Services Director, Sherril Denny. During the course of the investigation, LPA Sarangi interviewed staff members and residents in care. LPA reviewed resident records and facility records. In addition, during the opening of the complaint on February 18, 2025, LPAs toured the facility and made observations. Complaint alleges Personal Rights-Residents have the right be accorded dignity in their personal relationships with staff. Based on interviews that were conducted, LPA could not prove or disprove the above allegation occurred. Furthermore, during an interview with Resident #1, (Report continued on LIC 9099C) Unsubstantiated LPA learned that the resident feels comfortable in placement and that the caregiver is friendly. During questioning, Resident reported feeling safe and comfortable at the facility. Resident denies being uncomfortable around any caregiver. In addition, LPA observed the resident to be content in placement. LPA could not corroborate the allegation. Complaint alleges Food Service-Resident was not provided with the meal of their choice. Based on interviews that were conducted, LPA could not prove or disprove the above allegation occurred. Furthermore, during an interview with Resident #2, LPA learned that the caregiver got the resident the “special” off the food menu. However, Resident reported of not wanting that and instead wanting a hotdog. Caregiver served the hot dog that the resident requested. Resident also reported of feeling safe and content in placement. LPA could not corroborate the allegation. A finding that the complaint allegations of: Personal Rights-Residents have the right be accorded dignity in their personal relationships with staff and Food Service-Resident was not provided with the meal of their choice are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Residential Services Director.the state’s words, verbatim · CDSS document, Feb 24, 2025 · control 59-AS-20250213125948

Allegation investigated: Staff did not administer medication as prescribed.

On January 7, 2025 at approximately 09:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sundial Assisted Living for the purpose of conducting a complaint investigation inspection. LPA was greeted at the door by Administrator, Elizabeth Amlin and was granted access into the facility. During the course of the investigation, LPA Sarangi conducted interviews with staff, residents and a witness. LPA reviewed resident records and facility records. Complaint alleges that Staff did not administer medication as prescribed. Based on observation of the Medication Administration Record (MAR) conducted on January 7, 2025, LPA observed Resident #1 not receiving a dosage of medication on December 31, 2024 (See LIC 9099D). LPA conducted interviews with staff members and learned that a medication dosage was missed and documented on the Medication Administration Record (MAR). (Report continued on LIC 9099C) Substantiated LPA educated the Administrator and the Resident Care Director on the importance of ensuring that ALL residents are having their respective medications administered as outlined in the Medication Orders and Title 22 Regulation. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and emailed to the Administrator along with Appeal Rights. Complaint alleges that Facility is not adequately staffed to meet the needs of the residents in care. Based on observation, tour of the facility conducted on January 7, 2025 and interviews that were conducted, LPA could not corroborate the allegation. Furthermore, a review of the LIC 500 revealed sufficient staffing. During a tour of the facility conducted on said date, LPA observed sufficient staffing in place providing care and supervision to the resident population. LPA interviewed the Administrator and was advised that the facility has identified a staffing agency in case that the facility suffers through a staffing issue. During interviews with a sample of residents, LPA received inconsistent statements as it relates to the allegation. A finding that the complaint allegations of Staff did not prevent residents from having multiple falls while in care. Facility is not adequately staffed to meet the needs of the residents in care are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 59-AS-20250102142045

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 14, 2025

87465(c)(2) Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on an observation of the Medication Administration Record, LPA observed that facility staff missed a dosage of medication that was supposed to be administered to the resident in care which is a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Licensee/Administrator shall fill out an LIC 9098 understanding of the regulation. Furthermore, LPA requested the facility to conduct staff training by an outside agency to train on medication management, documentation and administration of medications to residents served. In addition, LPA requested the facility to provide proof of training and a statement on how future compliance will be met. POC Due date: February 7, 2025.

Allegation investigated: Resident developed a pressure injury while in care Staff are not distributing residents' medications as prescribed Staff are not answering residents' call buttons in a timely manner Staff do not ensure that residents' incontinence needs are met Licensee does not ensure that staff receives required training

On December 12, 2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sundial Assisted Living for the purpose of conducting a subsequent complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Elizabeth Amlin and was granted access into the facility. During the course of the investigation, LPA conducted interviews with staff, residents and witnesses. LPA reviewed facility records and staff records. Complaint alleges that Resident developed a pressure injury while in care. Based on interviews that were conducted, LPA could not prove or disprove the allegation. LPA conducted interviews with Resident #2 and Resident #3 and learned of no concerns with the care that is being provided. LPA received inconsistent statements and could not corroborate the allegation (Report continued on LIC 9099C). Unsubstantiated Complaint alleges that Staff are not distributing residents' medications as prescribed. Based on interviews that were conducted, LPA could not prove or disprove the allegation. During interviews with residents, staff and witnesses, LPA learned of no concerns as it relates to the medication management and dispensing of medication to residents. LPA could not corroborate the allegation. Complaint alleges that Staff are not answering residents' call buttons in a timely manner. Based on an observation of facility records, LPA could not prove or disprove the allegation. In addition, LPA conducted interviews and learned of no concerns as it relates to answering of the call bells in a timely manner. LPA could not corroborate the allegation. Complaint alleges that Staff do not ensure that residents' incontinence needs are met. Based on interviews that were conducted, LPA could not prove or disprove the allegation. Furthermore, during interviews with residents and Witness #1, LPA learned of no concerns as relates to the care of residents in placement. LPA could not corroborate the allegation. Complaint alleges that Licensee does not ensure that staff receives required training. Based on a review of facility records, LPA observed sufficient staff training for the Med Tech. In addition, during an interview with the Med Tech, LPA learned of no concerns as it relates to training of staff members at the facility. LPA could not corroborate the allegation. A finding that the complaint allegations of Resident developed a pressure injury while in care, Staff are not distributing residents' medications as prescribed, Staff are not answering residents' call buttons in a timely manner, Staff do not ensure that residents' incontinence needs are met, Licensee does not ensure that staff receives required training are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 59-AS-20241024103022

Allegation investigated: Staff stole resident's medication.

On December 12, 2024 at approximately 12:00 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sundial Assisted Living for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Elizabeth Amlin and was granted access into the facility. During the course of the investigation, LPA Sarangi reviewed the SOC 341 and LPA Sarah Benson conducted an interview with the Administrator on October 22, 2024. LPA Sarangi interviewed Resident #1 on December 12, 2024. Complaint alleges that Staff stole resident’s medication. Based on an observation of the SOC 341 that was submitted by the Administrator and the interview with the Administrator, the preponderance of evidence standard has been met. During the investigation, LPA learned that the alleged staff member had her belongings searched with no medication being found. (Report continued on LIC 9099C) Substantiated The Administrator advised that the facility has cameras in common areas including the Medication Room where medications are stored at. As a result, the alleged staff member vacated the position as a Caregiver (See LIC 9099D). LPA educated the Administrator on the importance of ensuring that all staff are competent to provide the services necessary to meet resident needs. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 59-AS-20241021143944

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 12, 2024

87411(a) 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 was not met as evidenced by: Based on an interview that was conducted with the Administrator on October 22, 2024, the alleged staff member had her belongings searched with no medication being found which is an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Licensee/Administrator should submit an LIC 9098-Self Certification and shall conduct staff training and provide proof of training. In addition, Licensee/Administrator shall provide a statement on how future compliance will be met. POC due on January 2, 2024 due to an extension request.

Allegation investigated: Residents are not being changed in a timely manner Resident are not receiving enough hydration Staff are doing finger sticks to check blood sugars Medications have been charted as given, but have not been Narcotics have been missing Staff do not check on resident's oxygen equipment at night, putting her at risk Staff did not refill resident’s medication prescription Staff was tested covid positive.

On September 19, 2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sundial Assisted Living for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Elizabeth Amlin and was granted access into the facility. During the course of the investigation, LPA reviewed facility records, resident records, interviewed staff, a former staff member and residents in care. LPA toured the facility on August 27, 2024, and September 9, 2024. Complaint alleges that residents are not being changed in a timely manner. Based on interviews that were conducted with Resident #1, LPA learned of no concerns as it relates to the allegation. Furthermore, LPA received inconsistent statements and could not corroborate the allegation. (Report continued on LIC 9099C) Unsubstantiated Complaint alleges that Resident are not receiving enough hydration. Based on interviews and observations that were conducted throughout the course of the investigation, LPA could not corroborate the allegation. Furthermore, LPA interviewed Resident #1 and learned that staff are attentive to the needs of the resident, and that the residents get plenty of food and water at the facility. Complaint alleges Staff are doing finger sticks to check blood sugars. Based on interviews that were conducted, LPA received inconsistent statements as it relates to the allegation. LPA learned that residents are assisted with checking of blood sugars which was confirmed by interviews with Former Staff Member #1, and the current Administrator of the facility. Complaint alleges that Medications have been charted as given but have not been. Based on observations of the Medication Administration Record (MAR) on August 27, 2024, LPA observed that medications have been charted appropriately. Furthermore, LPA did not have sufficient evidence to corroborate the allegation. Complaint alleges that Narcotics have been missing. Based on an interview that was conducted with Witness #1, LPA learned that a narcotic was missing on August 8, 2024, and documented in the Hospice Nurses Notes. However, the narcotics medications were found by the facility and not missing. On August 27, 2024, during the opening of the complaint, LPA reviewed the Medication Administration Record (MAR) for Resident #3 and observed the medication in question to be available, secured, and locked. LPA did not have sufficient evidence to corroborate the allegation. Complaint alleges that Staff do not check on resident's oxygen equipment at night, putting her at risk. Based on interviews that were conducted, LPA received inconsistent statements as it relates to the allegation. Furthermore, LPA could not corroborate the allegation. Complaint alleges that Staff did not refill resident’s medication prescription. Based on observations and interviews, LPA reviewed the Medication Administration Record (MAR) for Resident #1, #2 and #3 on August 27, 2024, and did not observe any concerns. LPA conducted interviews and received inconsistent statements during the interviews. LPA did not have sufficient evidence to corroborate the allegation. (Report continued on LIC 9099C) Complaint alleges that staff was tested covid positive. Based on interviews that were conducted, LPA learned that the facility followed their respective Infection Control Plan and kept the staff member at home. Furthermore, LPA received inconsistent statements as it relates to the allegation. LPA did not have sufficient evidence to corroborate the allegation. A finding that the complaint allegations of Residents are not being changed in a timely manner, Resident are not receiving enough hydration, Staff are doing finger sticks to check blood sugars, Medications have been charted as given, but have not been, Narcotics have been missing, Staff do not check on resident's oxygen equipment at night, putting her at risk, Staff did not refill resident’s medication prescription, Staff was tested covid positive are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator. Complaint alleges that Resident left on commode for long periods of time. Based on interviews that were conducted on August 27, 2024 with the Administrator, LPA learned that the former staff member accidentally left the resident on the commode for approximately 20 minutes. During an interview with the former staff member on September 12, 2024, at approximately 12:00 PM, LPA learned that the resident was left on the commode for 15 minutes. Former Staff Member was able to acknowledge this incident and was apologetic to the facility Administrator and to the LPA (See LIC 9099D). Complaint alleges that Staff did not charge resident’s oxygen tank. Based on interviews that were conducted with the Administrator on August 27, 2024, LPA learned that the resident’s oxygen tank was not plugged in all the way which subsequently led to the oxygen not dispensing to the resident (See LIC 9099D). LPA educated the Administrator on the importance of ensuring that all oxygen devices are functioning and operating normally. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in additional civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 59-AS-20240822111039

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(d) · Plan of correction due date: Sep 26, 2024

87211(a)(1)(d) 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 report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on interviews that were conducted on August 27, 2024, LPA learned that there were incident reports regarding residents’ health that was not reported to Community Care Licensing Division (CCLD) which presents a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee/Administrator to submit an LIC 9098 understanding of the regulation. In addition, Licensee and Administrator shall conduct staff training outlining Reporting Requirements. Licensee/Administrator shall provide a statement on how future compliance will be met. POC due date: September 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 20, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs… This requirement was not met as evidenced by: Based on interviews that were conducted, LPA learned that a resident was left on the commode for a long period of time which presents an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee/Administrator to submit an LIC 9098 understanding of the regulation. In addition, Licensee and Administrator shall conduct staff training outlining Observing the resident and documenting any changes. Licensee/Administrator shall provide a statement on how future compliance will be met. POC due date: September 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(b)(3)(h) · Plan of correction due date: Sep 20, 2024

87618(b)(3)(h) Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (H) Equipment shall be operable. This requirement was not met as evidenced by: Based on interviews that were conducted, LPA learned that the facility did not plug in the portable oxygen tank all the way which presents an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee/Administrator to submit an LIC 9098 understanding of the regulation. In addition, Licensee and Administrator shall conduct staff training outlining Oxygen Administration. Licensee/Administrator shall provide a statement on how future compliance will be met. POC due date: September 20, 2024

Type of visit: POC

On September 19, 2024 at approximately 11:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sundial Assisted Living for the purpose of conducting a Plan of Correction Inspection. LPA was greeted at the door by Administrator, Elizabeth Amlin and was granted access into the facility. LPA reviewed the entire Plan of Correction and found that to be appropriate. LPA cleared the citation and issued the POC letter. No deficiencies were observed or cited during today's Plan of Correction Inspection. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Required - 1 Year

On September 9, 2024 at approximately 11:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi met with Administrator, Elizabeth Amlin for the purpose of conducting a Required 1 year inspection. LPA and Administrator toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2024 at the time of the inspection. All smoke detectors sound directly to the fire station. Water temperature in facility bathroom measured at 108 degrees, within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of vacant and occupied bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility. LPA was made aware that the Facility Infection Control Plan is currently being updated. (See LIC 9102-Technical Advisory) First Aid kit was inspected and found to be appropriate during the inspection. Emergency Disaster Drill was last conducted in July 2024. LPA reviewed 5 of 5 resident files. However, during the medication review, LPA observed that 2 out of 5 residents did not have their prescribed medication (See LIC 809D). When LPA inquired about the medications, staff did not know if the medication has been discontinued or not. (Report continued on LIC 809C) LPA educated the Administrator on the importance of ensuring that all medications are afforded to the residents. LPA reviewed staff files and found those files to be appropriate during the review. LPA requested the following documents to be sent: LIC 500- Personnel Report LIC 308- Designation of Facility Responsibility LIC 309- Administrative Organization Most up-to-date Liability insurance Emergency Disaster Plan Control of Property Register of residents Most updated Infection Control Plan Most recent Fire Inspection Report Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.the state’s words, verbatim · CDSS document, Sep 9, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.