340318075-6-26-2024-27-AS-SRIN-D742SP-20240711173929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340318075
Report Date: 06/26/2024
Date Signed: 06/26/2024 03:25:08 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2024 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20240325153629

FACILITY NAME:	SUNSHINE GLORY CARE HOME		FACILITY NUMBER:	340318075
ADMINISTRATOR:	AGUDA, MERLY		FACILITY TYPE:	740
ADDRESS:	9845 ALTA MESA ROAD		TELEPHONE:	(916) 687-7874
CITY:	WILTON	STATE: CA	ZIP CODE:	95693
CAPACITY:	12	CENSUS: 12	DATE:	06/26/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Merly Aguda		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff are not qualified to care for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LP) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegation on 6/26/24 at 8:45am. LPA met with Merly Aguda and stated the purpose of the visit. LPA conducted an interview with Administrator during this visit.
Regarding allegation, "Facility staff are not qualified to care for residents," LPA observed during interviews on 3/29/24 of staff #2 and residents 1-7 that staff did seek lift assistance from other resident when R1 fell in the bedroom. In addition, S2 stated that English is the second language and Taglog is the first but S2 understands the residents and the residents understand S2 as well. During this visit LPA observed residents communicating with S2 in English to each other. Based on the interviews, and admittance by S2 the allegation is deemed substantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided. See 9099D

Substantiated

Estimated Days of Completion: 60

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2024 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20240325153629

FACILITY NAME:	SUNSHINE GLORY CARE HOME		FACILITY NUMBER:	340318075
ADMINISTRATOR:	AGUDA, MERLY		FACILITY TYPE:	740
ADDRESS:	9845 ALTA MESA ROAD		TELEPHONE:	(916) 687-7874
CITY:	WILTON	STATE: CA	ZIP CODE:	95693
CAPACITY:	12	CENSUS: 12	DATE:	06/26/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Merly Aguda		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility does not provide paper towels in resident bathroom
Resident bedrooms are full of debris and trash

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LP) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegations on 6/26/24 at 8:45am. LPA met with Merly Aguda and stated the purpose of the visit. LPA conducted an interview with Administrator during this visit.

Regarding allegation, "Facility does not provide paper towels in resident bathroom", LPA observed on 3/29/24 that there was paper towels, soap and tissue in the bathrooms. Today, LPA observed the Licensee installed a paper towel dispenser and electric hand dryer in the 2 resident bathrooms. Based on interviews with residents 1-7 and staff #2 on 3/29/24, the investigation revealed that prior to the writing of this complaint, the facility had a supply of paper towels for when the residents need or request it for bathroom use. Based on the diagnosis' of the residents who kept putting the paper towels in the toilet, the Administrator would keep a supply available and provide as needed along with individal hand towels for each resident. See 9099C for continuation...

Unsubstantiated

Estimated Days of Completion: 60

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20240325153629

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNSHINE GLORY CARE HOME	FACILITY NUMBER: 340318075
	VISIT DATE: 06/26/2024

NARRATIVE

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9099A Continued...

Regarding allegation, "Resident bedrooms are full of debris and trash", LPA observed on 3/29/24, that the staff was cleaning upon arrival. LPA also observed residents rooms during that visit. There was one room in particular Room 2 that was in need of cleaning. However, resident #6 (R6) would not allow staff to assist with cleaning although the roommate R8 cleans the room mostly trying to follow the house rules. LPA observed the House Rules #25 which indicates the following: "Residents are encouraged to assume the responsibility of making their own bed, keeping room neat and in an orderly fashion. Staff will make beds for those who can not for themselves. Residents must allow staff to thoroughly clean their room at least weekly and bathroom daily." LPA also observed that the rooms are cleaned by staff when residents who refuse assistance in cleaning are not present in the rooms.

The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per CCR (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20240325153629

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNSHINE GLORY CARE HOME	FACILITY NUMBER: 340318075
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/27/2024 Section Cited CCR 87411(i)	1 2 3 4 5 6 7	Personnel Requirements - General Residents shall not be used as substitutes for required staff but may, as a voluntary part of their program of activities, participate in household duties and other tasks suited to the resident's needs and abilities.	1 2 3 4 5 6 7	Licensee/Administrator shall submit by fax that there will be sufficient staff present to assist residents. Fax by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on S2 admitted to requesting a resident to assist with another resident for lifting purposes. However, R1 was lifted by EMT with no injuries. This violation poses a potential health, and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4