198603294-3-3-2022-11-AS-UCOL-CC6QUK-20220303112852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603294
Report Date: 03/03/2022
Date Signed: 03/03/2022 11:29:49 AM

Document Has Been Signed on 03/03/2022 11:29 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUNSHINE ASSISTED LIVING		FACILITY NUMBER:	198603294
ADMINISTRATOR:	MARY MONTIANO		FACILITY TYPE:	735
ADDRESS:	3141 EUCLID AVE		TELEPHONE:	(310) 638-3847
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY: 68		CENSUS: 57	DATE:	03/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Mary Jane Montiano		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Mary Jane Montiano, administrator. The facility is licensed to serve clients age range 18 through 59. Approved for up to 68 clients, of which 50 may be non-ambulatory. Approved hospice care waiver for 5 residents. There are currently 57 Department of Mental Health clients in placement. The facility has 2 buildings in total. One is referred to as the main building and the other as the annex. The main building consists of the lobby, main office, water fountain for drinking water, 22 bedrooms, 10 bathrooms 4 of which are private, 3 storage rooms, a laundry room, 1 garage for storage which is inaccessible to clients, a kitchen and dining area. There is a patio with seating and shade for client use in between the main building and the annex. The annex itself is a 2 story building with has 15 bedrooms, 3 bathrooms, administrators office and staff lounge area. LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 105.1 F and 111.3 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguishers were charged, smoke and Carbon Monoxide detectors were operable.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNSHINE ASSISTED LIVING	FACILITY NUMBER: 198603294
	VISIT DATE: 03/03/2022

NARRATIVE

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations located in common areas and restrooms. LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit LPA reviewed the staff schedule and interviewed the administrator, LPA did not observed the presence a full time activity staff who has full-time responsibility for the organization, conducting of and evaluation of planned activities, in order to ensure that all clients participate in accordance with their interests and abilities. Title 22, Division 6 and Chapter 6 is being cited on attached LIC809D form.

Plans of corrections were developed and exit interview held. A copy of the report and appeals rights was provided to was provided to Mary Jane Montiano, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/03/2022 11:29 AM - It Cannot Be Edited

Created By: Ulysses Coronel On 03/03/2022 at 10:53 AM

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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNSHINE ASSISTED LIVING	FACILITY NUMBER: 198603294
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85065(d)(2)(A)

Personnel Requirements. The licensee shall ensure that the following personnel requirements are met in the provision of planned activities: In facilities with a licensed capacity of 50 or more clients, one employee shall have full-time responsibility for the organization, conduct and evaluation of planned activities, and shall be given assistance as necessary in order to ensure that all clients participate in accordance with their interests and abilities. The designated employee shall possess at least one year of experience in organizing and providing planned group activities, and shall be knowledgeable in the evaluation of client needs, the supervision of other employees, and the training of volunteers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above the facility does not have an employeee who's full-time responsibility is to organize, conduct and evaluate planned activities,which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2022
	Plan of Correction
1 2 3 4	The administrator agreed to create a plan to ensure that the facility maintains an employeee who's full-time responsibility is to organize, conduct and evaluate planned activities. Proof of correctiion will be submitted by POC due 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.

SUPERVISOR'S NAME:

Janae Hammond

LICENSING EVALUATOR NAME:

Ulysses Coronel

LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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