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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045003002
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:22:52 PM


Document Has Been Signed on 06/20/2024 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SUNSHINE ASSISTED LIVING- THE HOUSEFACILITY NUMBER:
045003002
ADMINISTRATOR:BAKER, JENNAHFACILITY TYPE:
740
ADDRESS:1463 E. DOTTIE LANETELEPHONE:
(530) 872-0375
CITY:PARADISESTATE: CAZIP CODE:
95969
CAPACITY:15CENSUS: 9DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Administrator- Chad YoungTIME COMPLETED:
03:00 PM
NARRATIVE
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On 06/20/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Chad Young, and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed.

Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, and trash can with lids. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured above 120 degrees F in three locations within the facility. LPA observed the medications to be locked and inaccessible to residents.

LPA observed fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the first aid kit to be complete and ready for emergency use. LPA observed the emergency disaster plan to be complete but not updated or reviewed since 2021. The facility was unable to provide documentation that the emergency disaster drills were conducted over the last 12 months.

LPA reviewed a total of three (3) residents' files and five (5) staff files which contained all of the required documentation.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.


Several topics were discussed.

An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/20/2024 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SUNSHINE ASSISTED LIVING- THE HOUSE
FACILITY NUMBER: 045003002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the water measured above 120 degrees in three locations in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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The Administrator will create and implement a plan to ensure that water tempeture remains within the required range. The adminstrator will share the plan with the LPA.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview and record review, the licensee did not comply with the section cited above in that one of four emergency disaster drills were conducted within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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The Administrator will create and implement a plan to ensure that emergency disaster drills are conducted quarterly. The adminstrator will share the plan with the LPA
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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