079200335-4-14-2023-15-AS-PWAN-CQVUNH-20230414154357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200335
Report Date: 04/14/2023
Date Signed: 04/14/2023 03:44:11 PM

Document Has Been Signed on 04/14/2023 03:44 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CALIFORNIA SUNSHINE RCFE		FACILITY NUMBER:	079200335
ADMINISTRATOR:	CRYSTAL E VAKA		FACILITY TYPE:	740
ADDRESS:	5837 MITCHELL CANYON CT.		TELEPHONE:	(925) 693-0317
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY: 6		CENSUS: 4	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Crystal E Vaka, Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/14/2023 at 12:30 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Crystal Vaka and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility with Crystal including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPA observed locked gate around pool. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 108.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was purchased on 9/25/2022. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/22/20223. Report continues on 809 C.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE	FACILITY NUMBER: 079200335
	VISIT DATE: 04/14/2023

NARRATIVE

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At 12:45 PM LPA reviewed 4 residents records. At 1:10 PM LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. At 2:40 PM, LPA reviewed a sample of 3 resident’s medications.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
-At approximately 1:06 PM LPA observed resident files were incomplete. Resident 1 R1), R2 and R3 files are missing LIC 601, and LIC 603A. LPA observed R4 file to be empty, Administrator stated that their file was still at their previous facility and has not been brought to this facility.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided..

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2023 03:44 PM - It Cannot Be Edited

Created By: Paris Watson On 04/14/2023 at 02:31 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: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not have completed resident files for R1, R2, R3 and R4 which poses/posed a potential health, safety or personal rights risk to persons in care. R1, R2 and R3 files are missing LIC 601, and LIC 603A. R4 file was observed to be empty and did not obtain the required forms.
	POC Due Date: 05/01/2023
	Plan of Correction
1 2 3 4	Administrator will complete the required LIC forms, place them in the resident files and provide a photographic proof to CCL by POC date.

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:

Yvonne Flores-Larios

LICENSING EVALUATOR NAME:

Paris Watson

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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