SUNDIAL ASSISTED LIVING

Official classification

Type A

Official code

887631(a)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(17)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

The Administrator hired a dietitian that will perform the concultations and written records.

Deadline recorded: Jan 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Feb 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(f)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Tha administrator will complete a reappraisal training with staff. The administrator will notify LPA when complete.

Deadline recorded: Feb 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jan 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Nov 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87616(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jul 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Jul 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Deadline recorded: Jul 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(b)(2)(A)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jul 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jan 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Dec 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(d)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87618(b)(3)(h)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 5 residents did not have their prescribed medications secured in the cart. Facility staff does not know if the medications have been discontinued or not. This regulation poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/16/2024 Plan of Correction POC shall include a statement on how future compliance will be met. Submit an LIC 9098-Self Certification and conduct staff training.