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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609352
Report Date: 08/17/2022
Date Signed: 08/17/2022 01:55:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2022 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20220810134830
FACILITY NAME:SUNSHINE RESIDENTIAL HOME 3FACILITY NUMBER:
197609352
ADMINISTRATOR:JOSE, OYINLOYE AUSTINEFACILITY TYPE:
735
ADDRESS:17915 HEMMINGWAY STREETTELEPHONE:
(818) 666-5319
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:4CENSUS: 4DATE:
08/17/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Oyinloye JoseTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Staff did not ensure medication is inaccessible to residents
Insufficient staffing to meet the needs of residents in care
Facility is in disrepair
Staff do not maintain a safe environment for residents
INVESTIGATION FINDINGS:
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At 01:45 p.m. on 08/17/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Administrator and disclosed the reason for the visit.

Staff did not ensure medication is inaccessible to residents

Regarding the allegation above, Community Care Licensing (CCL) received a report on 08/09/2022 from a credible source confirming multiple medications were unlocked and accessible in a resident’s room on 08/01/2022 at approximately 10:45 a.m. LPA Reed did not observe any unlocked or accessible medications during a physical plant tour on 08/17/2022. Based on the observation of the credible source, the preponderance of evidence standard has been met. The above allegation is therefore deemed to be SUBSTANTIATED at this time. California Code of Regulations (Title 22, Division 6) are being cited on the attached LIC 9099-D.
Substantiated
Estimated Days of Completion: 8
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
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 4
Control Number 31-AS-20220810134830
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352
VISIT DATE: 08/17/2022
NARRATIVE
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Insufficient staffing to meet the needs of residents in care

Regarding the allegation above, CCL received a report on 08/09/2022 from a credible source stating there was 1 staff member providing care and supervision to 5 clients. The administrator confirmed the deficit in staffing, and another staff member arrived shortly thereafter. LPA Reed observed 4 staff for 3 clients during today’s inspection. Based on the observations of the credible source and interview, the preponderance of evidence standard has been met. The above allegation is therefore deemed to be SUBSTANTIATED at this time. California Code of Regulations (Title 22, Division 6) are being cited on the attached LIC 9099-D.

Facility is in disrepair

Regarding the allegation above, CCL received a report on 08/09/2022 from a credible source stating the tiles in a shower stall were “protruding outward in a very large section”. LPA observed the shower in good conditon. Based on observations from the credible source and LPA, the preponderance of evidence standard has been met. The above allegation is therefore deemed to be SUBSTANTIATED at this time. California Code of Regulations (Title 22, Division 6) are being cited on the attached LIC 9099-D.

Staff do not maintain a safe environment for residents

Regarding the allegation above, CCL received a report on 08/09/2022 from a credible source stating that bathroom rugs did not have skid resistant backings. LPA observed 2 newly purchased rugs with protective material during today’s inspection. Administrator confirmed the rugs were replaced since the credible source’s inspection on 08/01/2022. Based on the credible source’s observations, the preponderance of evidence standard has been met. The above allegation is therefore deemed to be SUBSTANTIATED at this time. California Code of Regulations (Title 22, Division 6) are being cited on the attached LIC 9099-D.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220810134830
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2022
Section Cited
CCR
80075(k)(1)
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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees.
This requirement is not met as evidenced by:
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Licensee ensured the medications were inaccessible during the 08/01/2022 visit from the credible source. Licensee has agreed to provide training from an approved vendor to all staff for medication storage protocol requirements and submit the proof of correction by the POC due date.
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Based on observation of a credible source, the licensee did not comply with the section cited above in approximately 4 medications which poses an immediate Health, Safety, and Personal Rights risk to clients in care.
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Type A
09/09/2022
Section Cited
CCR
85065.5(a)(2)
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85065.5 Day Staff-Client Ratio (a) ...the following minimum staffing requirements shall be met: (2) ...there shall be a staff-client ratio of no less than one direct care staff to three such clients.

This requirement was not met as evidenced by:
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Licensee has agreed to provide training for staff-client ratio to all staff. Licensee will submit proof of correction by the POC due date.
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Based on observation of a credible source, the licensee did not comply with the section cited above in 2 out of 5 clients which poses an immediate Health, Safety, and Personal Rights risk to clients in care.
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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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220810134830
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Licensee called for repairs on 08/02/2022. LPA observed the shower was in good condition during visit. POC cleared during visit.
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Based on the observation of a credible source, the licensee did not comply with the section cited above in 1 shower stall, which poses a potential Health, Safety, and Personal Rights risk to clients in care.
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Type B
09/09/2022
Section Cited
CCR
80087(b)(1)
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80087 Buildings and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
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Licensee replaced the rugs during the 08/01/2022 visit. POC cleared during visit.
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Based on the observation of a credible source, the licensee did not comply with the section cited above in 1 out of 2 bathrooms which poses a potential Health, Safety, and Personal Rights risk to clients in care.
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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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4