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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609554
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:51:40 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
03/26/2024 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20240326151647
FACILITY NAME:SUNSHINE RESIDENTIAL HOME WOODLEYFACILITY NUMBER:
197609554
ADMINISTRATOR:JOSE, OYINLOYE AUSTINEFACILITY TYPE:
735
ADDRESS:10534 WOODLEY AVENUETELEPHONE:
(818) 274-1809
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 3DATE:
09/19/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mojisola AdekunleTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not administer resident’s medication as prescribed
Staff did not comply with resident’s individual program plan
Facility is in disrepair
Facility has an infestation of cockroaches
Facility had expired and moldy food items
Facility did not ensure to maintain personnel records
INVESTIGATION FINDINGS:
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In conjunction with a Required Annual visit, Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to conclude the investigation regarding the above allegation. LPA met with staff/administrator...., and advised him/her of the complaint:

Staff did not administer resident's medication as prescribed:
In regards to the allegation, it was reported from another agency that on or around 02/29/24, a follow up inspection was made for a special incident report, that revealed Resident 1 (R1) did not receive assistance with their prescribed medication between 11/24/23 through 02/08/24. It was reported that there were about seventeen (17) seperate instances. The agency was able to identify more than thirty-four missed entries by staff for medications prescribed to R1. As a result, the facility was given a Corrective Action Plan (CAP). Based on the CAP and information provided by the outside agency, the allegation is Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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 5
Control Number 31-AS-20240326151647
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 WOODLEY
FACILITY NUMBER: 197609554
VISIT DATE: 09/19/2024
NARRATIVE
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Staff did not comply with resident’s individual program plan:
In regards to the allegation, it was reported from another agency that on or around 02/29/24, a follow up visit was made on a complaint report. It was alleged that on or around 01/17/24, R1 did not have the three required direct staff as necessary to ensure R1's health and safety stated on their Individual Program Plan (IPP) dated 09/12/23. According to this report, R1 has had three staff assigned to them since their admission to the facility on 06/23/23. As a result, the facility was given a Corrective Action Plan (CAP). Based on the CAP and information provided by the outside agency, the allegation is Substantiated.

Facility is in disrepair/Facility has an infestation of cockroaches:
In regards to the allegation, it was reported from another agency that on or around 02/29/24, an inspection was made to facility. During this inspection, it was observed by the agency that the toilet seat in the main bathroom was worn and needed replacement, and the umbrella, for the outdoor patio furniture was broken. Furthermore, during an inspection of the main bathroom, the agency observed a small cockroach crawling up the wall. As a result, the facility was given a Corrective Action Plan (CAP) follow up letter. Based on the CAP letter, and information provided by the outside agency, the allegation is Substantiated.

Facility had expired and moldy food items:
In regards to the allegation, it was reported from another agency that on or around 02/29/24, an inspection was made to facility. During this inspection, it was observed by the agency that there was expired lunch meat and a jar of peanut butter stored in the main refrigerator. There was also a small jar of moldy salsa and avocado dip. As a result, the facility was given a Corrective Action Plan (CAP) follow up letter. Based on the CAP letter and information provided by the outside agency, the allegation is Substantiated.

Facility did not ensure to maintain personnel records:
In regards to the allegation, it was reported from another agency that on or around 02/29/24, an inspection was made to facility. At the time of this inspection, it was observed by the agency that Staff 1 (S1) did not have a complete health screening (LIC 503) and Crisis Prevention and Intervention Certification (CPI). As a result, the facility was given a Corrective Action Plan (CAP) follow up letter. Based on the CAP letter and information provided by the outside agency, the allegation is Substantiated.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20240326151647
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 WOODLEY
FACILITY NUMBER: 197609554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2024
Section Cited
CCR
80075(b)(5)(B)
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Health Related Services- Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
Resident 1 (R1) did not receive assistance with their prescribed medication between 11/24/23 through 02/08/24. It was
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Licensee was given a Corrective Action Plan (CAP) due on 04/20/24. As POC, licensee will submit a copy of this plan to the licensing agency by 09/26/24
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reported that there were about seventeen (17) seperate instances, and the reporting agency was able to identify more than thirty-four missed entries by staff for medications prescribed to R1. This posed an immediate health & safety risk to the residents in care.
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Type A
09/19/2024
Section Cited
CCR
85078(a)(1)
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Responsibility for Providing Care and Supervision- The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by: Agency review that on or around 01/17/24, R1 did not have the
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Licensee was given a Corrective Action Plan (CAP) due on 04/20/24. As POC, licensee will submit a copy of this plan to the licensing agency by 09/26/24
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three required direct staff as necessary to ensure R1's health and safety stated on their Individual Program Plan (IPP) dated 09/12/23. This posed an immediate health & safety risk to the residents 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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20240326151647
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 WOODLEY
FACILITY NUMBER: 197609554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
CCR
80087(a)
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Building and Grounds- The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: On or around 02/29/24, an agency inspection observed the toilet seat in the main bathroom was worn and needed replacement, and the umbrella, for the
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In conjunction to this complaint investigation, LPA conducted an annual inspection. Physical plant, which includes the toilet in the main bathroom, the backyard furniture, which includes the umbrella were in good repair. Moreover, no insects or roaches observed on facilty grounds during the annual
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outdoor patio furniture was broken. Furthermore, during the inspection of the main bathroom, the agency observed a small cockroach crawling up the wall. This posed a potential health & safety risk to the residents in care.
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inspection. No further corrections required at this time.
Type B
09/19/2024
Section Cited
CCR
80076(a)(1)
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Food Services- All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. This requirement was not met as evidenced by: On or around 02/29/24, an agency inspection observed expired lunch meat and a jar of peanut butter stored in the main
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In conjunction to this complaint investigation, LPA conducted an annual inspection of the facility and did not observe any expired or spoiled food kept in the refrigerator or throughout the kitchen area during the inspection. No further corrections required at this time.
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refrigerator. There was also a small jar of moldy salsa and avocado dip. This posed a potentlal health & safety risk to the residents 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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240326151647
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 WOODLEY
FACILITY NUMBER: 197609554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
CCR
80065(f)(7)
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Personnel Requirements- All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill as appropriate to the job assigned and as evidenced by safe and effective job performance. On or around 02/29/24, an agency inspection and
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In conjunction to this complaint investigation, LPA conducted an annual inspection of the facility, which included a review of random staff records. Per review, required training and certification observed for staff. No further corrections needed at this time.
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record review was made. Per record review, S1 lacked Crisis Prevention and Intervention Certification (CPI). This posed a potential health and safety risk to the residents in care.
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Type B
09/19/2024
Section Cited
CCR
80066(a)(10)
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Personnel Records- The licensee shall ensure that personnel records, which includes health screenings are maintained for each employee. This requirement was not met as evidenced by: On or around 02/29/24, an agency inspection and record review was made. Per record review, S1 lacked a
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In conjunction to this complaint investigation, LPA conducted an annual inspection of the facility, which included a review of random staff records. Per review, the required health screening was observed for staff. No further corrections needed at this time.
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complete health screening (LIC 503). This posed a potential health & safety risk to the residents 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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5