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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003558
Report Date: 04/23/2024
Date Signed: 04/23/2024 10:24:22 AM

Document Has Been Signed on 04/23/2024 10:24 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SUNBEAM BARRIOS HOMEFACILITY NUMBER:
347003558
ADMINISTRATOR/
DIRECTOR:		BARRIOS, NORMANFACILITY TYPE:
735
ADDRESS:8579 PHEASANT HILL CTTELEPHONE:
(916) 988-5248
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 6DATE:
04/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Administrator, Norman BarriosTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst ( LPA ) Talwinder Bains conducted a case management visit to this facility on 04/23/24. LPA met with Administrator Norman Barrios and explained the purpose of today's visit.

The purpose of today's visit is to follow up Title 17 reviews conducted at this facility by Alta California Regional Center (ACRC) on 03/28/24. Facility Action Report (FAR) was generated by ACRC from the Title 17 reviews. Community Care Licensing Division (CCLD) received a copy of the FAR and it was noted in the FAR the facility was cited for violations that are in both Title 17 and Title 22. The visit today is to address the issues found in the FAR that apply to Title 22.

Based on the FAR report, the facility violated the following Title 22 violations:

1. It was observed by ACRC staff that Mucus DX in community PRN container however, the medication was not prescribed to a specific client. It was reported that facility staff utilized medication. Also observed in PRN supply was Allergy Relief (diphenhydramine + antihistamine) and Antacid that were both opened but there was no start date. It was unknown as to which client. PRNs ZzzQuil & Multi-symptom Cold & Flu relief were both opened with a start date on bottles of 1/23/24 however PRN Administration Log that start date for the medications was on 1/21/24.

2. PRN authorization letters for client #2 had order for PRN medication of Neosporin. It was reported by staff that Neosporin was in PRN supply but was destroyed due to it being expired however, there is no record of destruction on file.

**Report continued on 809-C....

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNBEAM BARRIOS HOME
FACILITY NUMBER: 347003558
VISIT DATE: 04/23/2024
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**Report continued from 809.....

3.PRN medications are not identified on Centrally Stored Medication and Destruction Record for clients.

4.Nystop 100,000 Powder listed on Centrally Stored Medication and Destruction Record (CSMDR) for client # 2 showed that it was filled on 3/12/2024 with start dates of 3/17/24 and 3/24/24. Medication is not on MAR nor in the facility. Staff provided D/C letter from Physician for 4/23/2023 and has not been used since. Staff was reprinting CSMDRs and did not remove medication from list after the D/C date.

5.Client #3 PRN authorization letter identifies Ibuprofen/Tylenol on the same line as if they are the same medication identifying dosage as 200mg and frequency as 1 tab q 4-6 hours.

6.Client # 4 PRN authorization letter identifies prescribed medication of Tussin which includes ingredients of Guaifenesin and/or Dextromethorphan. In PRN community supply there is only medication of ZzzQuil which includes ingredients of Dipenhydramine HCL & Acetaminophen as well as medication of Multi-symptom Cold & Flu relief daytime which includes ingredients of acetaminophen, dextromethorphan, and phenylephrine. Client utilized both medications from 1/21/24- 1/24/24 as identified on PRN Medication Administration log.

Based on the above, deficiencies are cited pursuant to California Code of Regulations, Title 22 and documented on the attached LIC809D.

Exit interview conducted and copy of report and appeal rights provided.





SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/23/2024 10:24 AM - It Cannot Be Edited


Created By: Talwinder Bains On 04/23/2024 at 07:50 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNBEAM BARRIOS HOME
FACILITY NUMBER: 347003558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services -
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not as evidenced by:
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Licensee shall send letter of understanding of this regulation to CCL by POC date-04/24/24. Additionally, Licensee shall satisfy the plan of correction with Alta California Regional Center and will send copies to CCL as well upon completion.
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Based on the FAR investigations issued by ALTA California Regional Center, the facility did not assist residents in care with medications as prescribed which posses an immediate health and safety risk to residents.
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Licensee shall send letter of understanding of this regulation to CCL by POC date-05/20/24. Additionally, Licensee shall satisfy the plan of correction with Alta California Regional Center and will send copies to CCL as well upon completion.
Type B
05/20/2024
Section Cited
CCR80075(k)(7)

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80075 Health Related Services-
(k) The following requirements shall apply to medications which are centrally stored:
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications...this requirement was not met as evidence by;
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Based on the FAR investigations issued by ALTA California Regional Center, the facility did not properly document and maintain centrally stored medication records as required which posses 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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
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