340318075-3-21-2022-27-AS-KHOS-CD22NL-20220330173254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340318075
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:32:12 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2022 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20220203133438

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:	DATE:	03/21/2022
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Merly Aguda		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey Canady arrived at the facility unannouced to deliever complaint investigation findings. LPAs met with Administrator Merly Aguda and explained the purpose of the visit. The Department has determined the following as it relates to the complaint allegation: Unlawful Eviction

On 12/10/2021, the department recieved notication regarding a eviction notice for Resident 1 (R1). The department approved the eviction notice based on R1 needing a higher level of care that the facility could provide. Administrator Merly stated R1's responsible party was notified verbally regarding the eviction prior to the department approving the eviction. Administrator Merly stated she extended the discharge date to Febraury 2022 to allow time to find placement. On Feburary 2, 2022, R1 discharged to live with family.

Continues on LIC 9099 - C..
Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220203133438

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNSHINE GLORY CARE HOME	FACILITY NUMBER: 340318075
	VISIT DATE: 03/21/2022

NARRATIVE

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Continued from LIC 9099

According to interviews with responsible parties (RP 1 and RP2), there was verbal discussion regarding Resident 1's behaviors, medical appointments, and eviction notice since late October and early November of 2021. However, RP1 stated an eviction noticed was not received until late December/early January. RP1 stated it was a surprise when Administrator Merly informed RP1 of the discharge date of 02/02/2022 because there was no clear conversation about the eviction. RP2 stated a copy of the notice was sent by RP1 to RP2 in early January 2022. RP2 stated RP1 was aware of the eviction and understood there was a time frame.

According to an interview with R1, R1 does not recall receiving an eviction notice or had conversations with staff about leaving the facility in February.

According to records review, the eviction notice was not signed by responsible parties or resident. Discharge documents were signed by RP1 and R1 on 02/02/2022. Discharge Documents were signed on 02/05/2022 by RP1 for R1's belongings.

According to records review and interviews, the administrator did not inform the payee of the discharge date and address change. A check was sent to Administrator Merly for February 2022 rent. Administrator Merly stated she sent the check back to the payee because of the discharge of R1.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. TA was provided due to eviction notices not being signed by RP1 and R1 and the payee not being notified of eviction. Exit interview was held and a copy of report was given to Administrator Merly

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC9099 (FAS) - (06/04)

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