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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200335
Report Date: 06/11/2021
Date Signed: 06/11/2021 01:02:43 PM

Document Has Been Signed on 06/11/2021 01:02 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 5DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Citadel Calpo, StaffTIME COMPLETED:
01:15 PM
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On 06/11/21 at 10AM, Licensing Program Analyst (LPA) conducted an infection control annual inspection and explained the purpose of the visit with S1 and S2. LPA observed Administrator was not available during visit. LPA observed one central entry point designated for universal entry screening at the main entrance.

LPA observed COVID-19 signages in common areas. LPA observed hand sanitizer, gloves and face masks available outside the main entrance. LPA observed S2 wearing face mask and S1 not wearing face mask during visit. LPA advised S1 to wear a face mask at all times while working at the facility. Facility has a completed mitigation plan in place dated 02/01/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Per staff, the designated infection control leader is the administrator.

LPA observed locked medication cabinets located near the kitchen area. LPA observed unlocked toxic chemical cabinet (Disinfectants, Febreze air freshener, Lysol, Windex, PRN medications, WD 40) in the main hallway. LPA advised staff to lock the toxic chemical cabinet during visit.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/11/2021
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Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since March 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 74 degrees Fahrenheit. Fire extinguisher was observed fully charged and last inspected on 08/27/20. Smoke and Carbon monoxide detectors were operational. A written Emergency/Disaster plan dated 03/01/2021 was posted in a common hallway leading to the kitchen. Centrally stored medications were locked in kitchen cabinets. Sharp objects were locked in the kitchen drawers.

LPA also advised staff to let administrator know that their annual fee is past due and needs to be paid as soon as possible to avoid additional late fees.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2021 01:02 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 06/11/2021 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE
FACILITY NUMBER: 079200335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)


This requirement is not met as evidenced by: Toxic chemicals were stored unlocked in the cabinet located in the main hallway leading to residents' bedrooms.
Deficient Practice Statement
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Based on observation, toxic chemicals were stored in an unlocked hallway cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2021
Plan of Correction
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S2 corrected deficiency during visit. Lock was placed on the cabinet by S2 where toxic chemicals are stored.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2021 01:02 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 06/11/2021 at 12:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE
FACILITY NUMBER: 079200335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During visit, LPA observed S1 did not wear a face mask which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2021
Plan of Correction
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S1 corrected deficiency during visit. S1 wore a face mask and was reminded by LPA to wear a face mask at all times while at the facility.

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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2021


LIC809 (FAS) - (06/04)
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