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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200335
Report Date: 05/20/2025
Date Signed: 05/20/2025 06:15:54 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2024 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241211144727
FACILITY NAME:CALIFORNIA SUNSHINE RCFEFACILITY NUMBER:
079200335
ADMINISTRATOR:CRYSTAL E VAKAFACILITY TYPE:
740
ADDRESS:5837 MITCHELL CANYON CT.TELEPHONE:
(925) 693-0317
CITY:CLAYTONSTATE: CAZIP CODE:
94517
CAPACITY:6CENSUS: 2DATE:
05/20/2025
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Mateaki Ofahengaue, ManagerTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff failed to address resident’s urinary catheter needs while in care
Staff failed to provide appropriate care resulting in resident skin tears
INVESTIGATION FINDINGS:
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On 5/20/2025 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Manager, Mateaki Ofahengaue and explained the purpose of the visit.

During the course of investigation, LPA interviewed 3 residents and staff. LPA also obtained and reviewed physician's report, emergency information, and pre-placement appraisal.

Staff failed to address resident’s urinary catheter needs while in care
Interview with resident (R3) revealed that staff assist in emptying urinary bag. R3 stated staff will assist resident when asked. Facility did not have pre-placement appraisal or a current appraisal needs and service plan for R3 indicating care provided.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20241211144727
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CALIFORNIA SUNSHINE RCFE
FACILITY NUMBER: 079200335
VISIT DATE: 05/20/2025
NARRATIVE
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Staff failed to provide appropriate care resulting in resident skin tears
Facility did not have a current appraisal needs and service plan for R3 to indicate specific care needs. Interview with resident (R3) revealed that R3 can reposition and turn independently, but staff have assisted R3 in transfers. R3 stated staff will provide assistance when asked.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Mateaki. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2