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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318075
Report Date: 04/10/2023
Date Signed: 04/10/2023 11:28:55 AM


Document Has Been Signed on 04/10/2023 11:28 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SUNSHINE GLORY CARE HOMEFACILITY NUMBER:
340318075
ADMINISTRATOR:AGUDA, MERLYFACILITY TYPE:
740
ADDRESS:9845 ALTA MESA ROADTELEPHONE:
(916) 687-7874
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY:12CENSUS: 11DATE:
04/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Merly AgudaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during an office meeting on 02/18/2020. LPA met with Administrator Merly Aguda, and explained the purpose of the visit.

LPA toured the physical plant to ensure compliance with Title 22 regulations. Today, there were 3 staff on shift. LPA observed 3 resident bedrooms, 3 bathrooms, common areas, and exterior plant. LPA observed resident bedrooms and bathrooms to have necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. Bathrooms were stocked with paper towels, soap, and hand rails. LPA observed the common area floors and bathroom floors to be stained with dirt or old stains. Administrator stated that the floors are cleaned but the stains would not come out. This poses a potential health and safety risk to residents in care. Sheds in the backyard area were observed to be used for storage.

LPA requested to review 2 resident files and 3 staff files. LPA observed Administrator Certificate for Merly Aguda to be up to date with an expiration date of 06/29/23. Administrator Merly stated she is working on her renewal application. The 3 staff files were observed to be within compliance of Title 22 regulations. 1 out of 2 resident files were not within compliance due to an appraisal services and needs form not being updated.

During the visit, residents were observed to be smoking in the designated area, watching television in the common area, completing ADLs, and receiving assistance from staff. Staff were observed cleaning, cooking lunch, assisting residents with calls, prompting residents with daily reminders, and observed speaking positively and encouraging.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during this visit. Appeal Rights were provided. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
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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Document Has Been Signed on 04/10/2023 11:28 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SUNSHINE GLORY CARE HOME
FACILITY NUMBER: 340318075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2023
Section Cited

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87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times....(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by:
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Licensee stated that they will do a power wash of the of floors, clean the surrounding areas with bleach, obtain a quote of the flooring. Licensee to submit proof of services and cleans floors by POC due date.
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Based on observations, the floors in the hallway near resident bedrooms and in the main rooms were not maintained clean, sanitary, or in good repair. This poses a potential health and safety risk to residents in care.
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Type B
05/10/2023
Section Cited

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87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, or once every 12 months, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by:
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Licensee stated she will update the forms, send a faxed copy, and will review the regulation 87463. LPA to receive a written notification of understanding for 87463 by POC due date.
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Based on records review, the licensee did not ensure 1 out of 2 resident files reviewed had an updated appraisal services and needs form completed. This poses a potential health and safety risk to 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
LIC809 (FAS) - (06/04)
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