306002996-8-1-2024-22-AS-KLYN-D7PUMR-20240731154246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002996
Report Date: 07/31/2024
Date Signed: 08/01/2024 08:08:19 AM

Document Has Been Signed on 08/01/2024 08:08 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SUNSHINE RETIREMENT HOME		FACILITY NUMBER:	306002996
ADMINISTRATOR:	MARIETA MARQUEZ		FACILITY TYPE:	740
ADDRESS:	17846 TACOMA CIRCLE		TELEPHONE:	(714) 532-6885
CITY:	VILLA PARK	STATE: CA	ZIP CODE:	92861
CAPACITY:	6	CENSUS: 3	DATE:	07/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Marieta Marquez and Stanley Soliven		TIME COMPLETED:	04:05 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 Analysts (LPAs) Kimberly Lyman and Samer Haddadin conducted an unannounced visit to Sunshine Retirement Home. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents with a hospice waiver for 2. There are no residents on hospice during today's visit. Administrator Marieta Marquez has an administrator certificate valid until 10/30/2024. LPAs along with Administrator Marieta Marquez toured the facility at 1:35 PM. LPAs toured the physical plant, checked food service, first aid kit and reviewed records. Facility appears to be clean, safe, and sanitary. The home consists of five resident bedrooms, 2 common restrooms, resident restroom, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPAs observed two residents with half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 118.7 and 122.5 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the elements including thermometer, tweezers and scissors. LPAs observed toxins are secured during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked and self latching. LPAs observed ample emergency food supply. LPAs reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility does not have documentation of last fire drill conducted. CONT ON LIC809-C DATED 07/31/2024.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE RETIREMENT HOME	FACILITY NUMBER: 306002996
	VISIT DATE: 07/31/2024

NARRATIVE

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Facility provides activities per resident request. At 2:20 PM, LPAs reviewed three resident files and four staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Two out of two residents with bed rails do not have corresponding physician orders for rails. Staff files reviewed contained required documentation of medical clearance/ TB, CPR training and criminal record clearance. At 2:45 PM, LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2024 08:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE RETIREMENT HOME	FACILITY NUMBER: 306002996
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Facility does not have current liability insurance which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Licensee to obtain liability insurance and forward proof to LPA by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Facility has not conducted an emergency drill this year which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Facility to conduct an emergency drill and forward proof to LPA 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 08/01/2024 08:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE RETIREMENT HOME	FACILITY NUMBER: 306002996
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident ... Postural supports may be used under the following conditions: A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of two residents with bed rails. Facility does not have written physician orders for bed rails. This poses a potential health and safety risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Licensee to obtain written physician orders for bed rails and forward proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

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