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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200218
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:40:23 AM

Document Has Been Signed on 10/03/2023 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNNY HOMEFACILITY NUMBER:
079200218
ADMINISTRATOR:CALIN NICULESCUFACILITY TYPE:
735
ADDRESS:1612 ENID DRIVETELEPHONE:
(925) 323-4068
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 6CENSUS: 5DATE:
10/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Calin Niculescu, AdministratorTIME COMPLETED:
11:50 AM
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On 10/3/2023 at 10:50 am Licensing Program Analyst J. Clancy-Czuleger arrived unannounced for a Case Management visit regarding an incident that was reported to CCLD on 10/2/2023. LPA met with administrator Calin Niculescu and explained the purpose of the visit.

Incident report for C1 was sent on 10/02/2023 and occurred on 9/29/2023 when C1 passed away. The administrator stated that C1 tested positive for Covid on 9/18/2023 and went to the hospital on 9/19/2023 for a fever of 103 degrees and was sent home the same day with a confirmed test of Covid. On 9/21/2023 C1 requested to go to the hospital as he was still not feeling well, and there he was given a X-Ray and was prescribed Paxlovid and sent home. On 9/26/2023 C1 tested negative for Covid. On 9/28/2023 staff observed C1 to be lethargic and not himself, they offered to take him to the hospital again but C1 declined. C1 passed in their sleep on 9/29/2023 and was found in the morning by the staff.

LPA collected a copy of the Client’s medical assessment and recent hospital discharge papers. LPA requested a copy of the death report.

No deficiencies are being cited on this date.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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