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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609352
Report Date: 01/31/2025
Date Signed: 01/31/2025 02:20:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
07/31/2024 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20240731152949
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:
01/31/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Toluwalope Jose, Administrator DesigneeTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff administered medication(s) to resident in care without physician's approval.
Unqualified staff administered medication(s) to resident in care.
Licensee does not ensure that staff are adequately trained.
Licensee did not ensure that staff member got a TB clearance before providing care to residents.
Licensee is financially abusing resident(s) in care.
INVESTIGATION FINDINGS:
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At 12:00 PM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced subsequent complaint visit. LPA met with the Administrator Designee, Toluwalope Jose, and LPA disclosed the reason for the visit.

To investigate the allegations above LPA Rahimi, conducted an initial visit on 08/02/2024 and LPA requested copies of pertinent information relevant to the course of investigation. Between 10:00 AM – 12:00 PM, LPA conducted an interview with the designee, Two (2) staff, and one (1) out of two (2) clients who were able to communicate.
On 12/05/2024, LPAs Rahimi and Panushkina conducted a subsequent visit and LPAs requested additional copies of pertinent information which included, but not limited to Centrally Stored Medication and Destruction Record (CSMDR), Physician's Report, Record of Client Safeguard Cash Resources and Staff training/records relevant to the investigation. Between 10:10 AM – 1:15 PM, LPAs conducted an interview with the designee, and one (1) staff. Continue on LIC 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
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 7
Control Number 31-AS-20240731152949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352
VISIT DATE: 01/31/2025
NARRATIVE
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Staff administered medication(s) to resident in care without physician's approval.

It was reported that during the annual visit conducted on 07/30/2024, by the credible witness from North Los Angeles Regional Center ( NLARC) that the facility staff administered prescribed PRN sedatives to C1 without Physician approval. To investigate this allegation LPAs conducted an interview with the Administrator Designee who confirmed that C1 was provided Atarax on January 10th, 11th, and 16th and as well on April 15th 2024 without PRN authorization from the attending Physician. Additionally, Administrator Designee was not able to provide any PRN forms regarding this medication and also confirmed that the facility failed to properly document C1's PRN medication intake. Therefore, based on the interviews and information gathered this allegation is Substantiated.

Unqualified staff administered medication(s) to resident in care.

It was reported that during the annual visit conducted on 07/30/2024, by the credible witness from NLARC that Staff #1 (S1) who provided medication to C1 was not qualified/licensed to provide medication without Physician's direction and approval. To investigate this allegation, LPAs conducted an interview with the Administrator Designee who confirmed that S1 failed to contact C1’s physician prior to providing C1’s PRN medication nor documented any communication with the Physician. Additionally, review of C1’s file review revealed that C1 is nonverbal and is unable to determine his/her own needs for prescription or nonprescription PRN medication. Furthermore, interview with S1 also confirmed that no report was submitted to the Physician and S1 was not aware of PRN medication policy. Based on the record review and interview this allegation is Substantiated.

Licensee does not ensure that staff are adequately trained.

It was reported that during the annual visit conducted on 07/30/2024, by the credible witness from NLARC that facility staff did not receive required training. To investigate the allegation, LPAs conducted file review of staff. Review of personnel file records revealed that personnel records, including certifications of Direct Support Professional (DSP) training, and training logs, are not in compliance. Moreover, interview with the Administrator Designee confirmed that the DSP training for the first and second year of employment were not completed for two (2) staff members. Therefore, based on personnel file records review and interview, this allegation is Substantiated.

Continue on LIC 9099C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 31-AS-20240731152949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352
VISIT DATE: 01/31/2025
NARRATIVE
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Licensee did not ensure that staff member got a TB clearance before providing care to residents.

It was reported that during the annual visit conducted on 07/30/2024, by the credible witness from NLARC that the facility staff did not have a TB test. To investigate this allegation, LPAs conducted an interview with the Administrator Designee who confirmed that S2 did not have any TB test clearance on LIC 503 (Health Screening Report) form. Additionally, LPA conducted review of S2's facility records and observed that S2 got hired in September 2023 and was not TB tested and cleared until July 2024. Therefore, based on documentation review and interview, the allegation is Substantiated.

Licensee is financially abusing resident(s) in care.

It was reported that during the annual visit conducted on 07/30/2024, by the credible witness from NLARC that the facility is not keeping funds records in chronological order by co-mingling and releasing funds to others than the clients. To investigate this allegation LPA conducted an interview with the Administrator Designee who confirmed that funds were not safeguarded as indicated in C1’s admission agreement and were released to C1's responsible party. Proof of P & I funds were not provided to the facility.

Moreover, interview with Administrator Designee also confirmed that the facility used personal credit card for C2 which the funds were later reimbursed from C2’s P & I fund. Based on the information gathered there is enough evidence to support this allegation; therefore, the allegation is Substantiated.

Deficiencies cited during today's visit. Appeal rights explained.

Copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 31-AS-20240731152949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 01/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2025
Section Cited
CCR
80075(b)(6)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for ....or nonprescription PRN medication, ..........:
This requirement is not met as evidenced by:

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Licensee was given a Corrective Action Plan (CAP) due on 09/15//24. As POC, licensee l provided copy of the training completion and POC cleared during today's visit.
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Based on record review the licensee did not comply with the section cited above in giving sedative medication to C1 without following proper guidelines and C1 was overmedicated which poses a potential health, safety or personal rights risk to persons in care.
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Type A
02/04/2025
Section Cited
CCR
80065(g)(1)
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Personnel Requirements (g) All personnel, including the licensee, administrator and volunteers, shall be in good health,.....(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis,.....
This requirement is not met as evidenced by:

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Administrator informed LPA that S2 is no longer working for the company as of August of 2024. POC cleared during today's visit.
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Baed on interviews and record reviews licensee did not comply with the section cited above by not having S2 TB cleared prior to employment with the facility which poses a potential health, safety or personal rights risk to persons 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 31-AS-20240731152949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 01/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2025
Section Cited
CCR
80026(e)(1)(A)
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80026-Safeguards for Cash Resources.....(e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.(1) Records of clients' cash resources..... a current ledger accounting........(A) Receipts for cash provided to any client from his/her account(s).....amount and date received, as follows:
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Administrator agreed that the Administrator and all direct care staff will receive training from a vendor on Personal and Incidental Funds and proof will be submitted to LPA by the POC due date.
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Based on record review and interviews, the licensee did not comply with the section cited above by comingling C2's funds and releasing C1's funds to a person other than C1, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/07/2025
Section Cited
CCR
80065(a)(f)
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80065 Personnel Requirements: Facility personnel shall be competent to provide the services necessary to meet...... (f) All personnel shall be given on-the-job training ....., ......evidenced by safe and effective job performance
This requirement was not met as evidenced by:
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Administrator Designee provided copy of the on-the-job training for all staff and DPS training certificates for two staff to the LPA during today's visit. POC cleared during the visit.
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Based on interview, and record review, the licensee did not comply with the section cited above in not providing on-the-job training to all the staff & DSP training for two staff, which poses/posed a potential health, safety or personal rights risk to persons 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
07/31/2024 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20240731152949

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:
01/31/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Toluwalope Jose, Administrator DesigneeTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff overmedicated resident in care.
INVESTIGATION FINDINGS:
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3
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5
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10
11
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At 12:00 PM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced subsequent complaint visit. LPA met with the Administrator Designee, Toluwalope Jose, and LPA disclosed the reason for the visit.

To investigate the allegations above LPA Rahimi, conducted an initial visit on 08/02/2024 and LPA requested copies of pertinent information relevant to the course of investigation. Between 10:00 AM – 12:00 PM, LPA conducted an interview with the designee, Two (2) staff, and one (1) out of two (2) clients who were able to communicate.
On 12/05/2024, LPAs Rahimi and Panushkina conducted a subsequent visit and LPAs requested additional copies of pertinent information which included, but not limited to Centrally Stored Medication and Destruction Record (CSMDR), Physician's Report, Record of Client Safeguard Cash Resources and Staff training/records relevant to the investigation. Between 10:10 AM – 1:15 PM, LPAs conducted an interview with the designee, and one (1) staff. Continue on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 31-AS-20240731152949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352
VISIT DATE: 01/31/2025
NARRATIVE
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Staff overmedicated resident in care:
It was reported that during the annual visit conducted on 07/30/2024, by the credible witness from North Los Angeles Regional Center ( NLARC) that the facility staff overmedicated C1 with Atarax. To investigate this allegation LPAs conducted an interview with the Administrator Designee and was informed that although the Physician was not contacted each time PRN medication was given to C1, the facility staff followed the instruction on the bottle and documented on Medication Administration Record (MAR). During the initial visit conducted by LPA Rahimi record review of MAR and a copy of C1's medication prescription were obtained. Review of the prescription revealed that C1 was ordered to take one tablet ever six (6) hours PRN. However, review of MAR revealed that the facility staff administrated medication only one tablet on January, 10, 11, and 16, and as well as on April 15th 2024. Additionally, no incident was submitted to CCLD regarding C1’s hospitalization due to overmedication. Based on doctor's instruction and MAR there is insufficient evidence to proof that the facility staff overmedicated C1; therefore, this allegation is Unsubstantiated at this time.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7