045003003-6-20-2024-59-AS-JBOS-D6EU9U-20240620152344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045003003
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:24:22 PM

Document Has Been Signed on 06/20/2024 03:24 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 COTTAGE		FACILITY NUMBER:	045003003
ADMINISTRATOR:	BAKER, JENNAH		FACILITY TYPE:	740
ADDRESS:	1468 SUN MANOR		TELEPHONE:	(530) 887-3363
CITY:	PARADISE	STATE: CA	ZIP CODE:	95969
CAPACITY:	17	CENSUS: 15	DATE:	06/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator- Chad Young		TIME COMPLETED:	01:00 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. LPA observed two residents who are using oxygen and did not have the proper signage posted on the outside of the residents room. Areas toured include but are not limited to: common areas, resident bedrooms, shower rooms and common restrooms. LPA observed all resident bedrooms to have all the required furnishings, proper lighting and windows with screens. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, and trash can with lid.

LPA observed the temperature in the building to be appropriate for the weather. LPA observed the kitchen to be clean and organized. 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 at 113 degrees F.

LPA observed four (4) fire extinguishers, fire detectors, and carbon monoxide detectors. 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 observed the first aid kit was was complete and ready for emergency use.

LPA reviewed a total of six (6) residents' files and five (5) staff files. The resident files did not contain doctors orders in the files for the residents who have half bed rails. Four of the resident files reviewed had half bed rails and no order from a doctor in the file. The employee files contained all of the required documentation.

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (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)

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Document Has Been Signed on 06/20/2024 03:24 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 COTTAGE	FACILITY NUMBER: 045003003
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on interview, and record review, the licensee did not comply with the section cited above in one of four emergency disaster drils was conducted and/or documented within the last 12 months which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2024
	Plan of Correction
1 2 3 4	The Administrator will create and implement a plan to ensure that emergency disaster drills are conducted at least quartlerly. The administrator will share this plan with the LPA by 6/27/24.

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in four out of six resident files reviewed had bed rails with not order from a doctor in the file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2024
	Plan of Correction
1 2 3 4	The Administrator will request updated medical orders for the bed rails for residents who have bed rails, or remove the bed rails from the resident beds who have the bed rails. The Administrator will inform the LPA of which of the two options above the facility will take. The Administrator will provide the LPA with documentation.

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (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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Document Has Been Signed on 06/20/2024 03:24 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 COTTAGE	FACILITY NUMBER: 045003003
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(B)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that two residents who have oxygen did not have the appropriate signage posted on the residents door which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that the proper signage is posted on residents door when oxgen is in use. Adminstrator inform the LPA that the signage is posted.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (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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