347004408-2-15-2023-27-AS-AMAZ-CP3QBJ-20230215110136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004408
Report Date: 02/15/2023
Date Signed: 02/15/2023 11:01:43 AM

Document Has Been Signed on 02/15/2023 11:01 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:	SUNNY BEACH VILLA		FACILITY NUMBER:	347004408
ADMINISTRATOR:	DIMITROVA, DESSI		FACILITY TYPE:	740
ADDRESS:	2506 CASTLEWOOD DR		TELEPHONE:	(916) 486-4265
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	6	CENSUS: 4	DATE:	02/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Dessi Dimitrova		TIME COMPLETED:	11:00 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Avelina Martinez, Arielle Pascua, and Pang Lee made an unannounced visit to this facility to conduct an annual inspection on 02/15/2023 at 9:35 AM. LPAs met with Dessi Minitrova and stated the purpose of today’s visit. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires on 05/11/2024. The facility is licensed for six non-ambulatory residents and has a hospice waiver for two. There are currently four residents who reside at this facility.

LPA Martinez toured the facility with Dessi Dimitrova on 02/15/2023 at 10:00 AM.

The facility had Covid-19 postings throughout the facility. The facility has one main Covid-19 screening entry point. LPAs inspected smoke detectors and and carbon detectors, which were in good repair. The fire extinguisher did not have an inspection tag. The facility had an adequate food supply. LPAs reviewed staff and resident files and they were up to date. The facility has first aid kit and a locked medication cabinet. The facility water temperature measured at 105 degrees and the facility temperature measured at 76 degrees. The facility needs some cleaning and unused furniture needs to removed from the residents patio area. The exterior emergency exit door opens, however, the latch needs to be repaired. Technical violations were given, as the Licensee is currently working on removing unused furniture and repairing exterior gate. The facility has a public telephone and has an area for activities.

As a result of this visit, the following deficiency was cited, per California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted and copy of the 809 report, 809D page, and appeals rights were given to administrator at the end of visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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 02/15/2023 11:01 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: SUNNY BEACH VILLA	FACILITY NUMBER: 347004408
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

87202(a) Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The facility fire extinguisher did not have a inspection tag, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2023
	Plan of Correction
1 2 3 4	Licensee agrees to have fire extinguisher inspected and tagged. Licensee will email LPA Martinez a picture of tagged fire extinguisher by POC Date 2/16/23 by 5 PM.

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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