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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200335
Report Date: 05/20/2025
Date Signed: 05/20/2025 06:10:26 PM

Document Has Been Signed on 05/20/2025 06:10 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/
DIRECTOR:		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
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Mateaki Ofahengaue, ManagerTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 5/20/2025 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Manager, Mateaki Ofahengaue and explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, and outdoor area. Smoke and carbon monoxide detectors were observed. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 112.1 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mats/materials in the bathrooms. Resident rooms were observed to be cleaned and fully furnished. Fire extinguisher was observed to be full. First Aid kit is complete. Last fire drill was conducted on 3/15/2025. LPA reviewed 2 residents and 3 staff files starting at 12:30PM. LPA reviewed a sample of resident's medications during inspection.

At 11:30AM, LPA observed unlocked knives drawer, unlocked cleaning supplies in bathrooms, and unlocked gardening tools in the backyard. Manager locked up the items during inspection.

At 12:40PM, LPA observed R1 does not have admission agreement on file.

At 12:45PM, LPA observed R2 does not have medical assessment and TB test on file.

At 12:50PM, LPA observed R1 and R2 does not have current reappraisal needs and service plan on file.
(Continue on LIC809C...)
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Grace Luk
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
Page: 1 of 15
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 15
Document Has Been Signed on 05/20/2025 06:10 PM - It Cannot Be Edited


Created By: Grace Luk On 05/20/2025 at 04:05 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: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked knives, cleaning supplies, and unlocked gardening which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Manager locked up the items during inspection.
Deficiency cleared.
Civil penalty of $250 is being assessed for a repeat violation.
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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Grace Luk
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 15
Document Has Been Signed on 05/20/2025 06:10 PM - It Cannot Be Edited


Created By: Grace Luk On 05/20/2025 at 04:05 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: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test which poses a potential health and safety risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Facility agreed to obtain health screening for S2 and S3, and TB test for S2. Facility will submit documents to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Grace Luk
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 05/20/2025 06:10 PM - It Cannot Be Edited


Created By: Grace Luk On 05/20/2025 at 04:05 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: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current CPR and First Aid training for staff which poses a potential health and safety risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Facility has agreed to obtain current CPR and First Aid training for S2 and S3. Facility will submit documents to CCLD by POC date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having medical assessment and TB test for R2 which poses a potential health and safety risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Facility has agreed to obtain medical assessment and TB test for R2. Facility will submit documents to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Grace Luk
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 05/20/2025 06:10 PM - It Cannot Be Edited


Created By: Grace Luk On 05/20/2025 at 04:05 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: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current reappraisal needs and service plans for residents which poses a potential health and safety risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Facility has agreed to obtain current needs and service plans for R1 and R2. Facility will submit the documents to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Grace Luk
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
Page: 6 of 15
Document Has Been Signed on 05/20/2025 06:10 PM - It Cannot Be Edited


Created By: Grace Luk On 05/20/2025 at 04:05 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: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above by not having admission agreement for R1 which poses a potential health and safety risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Facility agreed to obtain R1's admission agreement and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
87458(b)
(b) The licensee shall obtain an updated medical assessment when required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not having an updated medical assessment for R1 with current ambulatory status which poses a potential health and safety risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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3
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Facility agreed to obtain an updated medical assessment for R1 with current ambulatory status and submit a copy to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Grace Luk
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
Page: 7 of 15
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: 05/20/2025
NARRATIVE
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At 1:15PM, LPA observed S2 and S3 does not have health screening and S2 does not have TB test on file.

At 1:20PM, LPA observed no staff on duty have current CPR and First Aid training.

At 2:00PM, LPA observed R1's medical assessment states that R1 is bedridden and on hospice care. LPA was informed by manager that R1 is no longer on hospice care. The facility does not have a bedridden fire clearance. Interview with R1 revealed that R1 can move side and side independently.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with Mateaki. A copy of this report, civil penalty, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Grace Luk
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
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