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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004408
Report Date: 04/10/2025
Date Signed: 04/11/2025 03:41:00 PM

Document Has Been Signed on 04/11/2025 03:41 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SUNNY BEACH VILLAFACILITY NUMBER:
347004408
ADMINISTRATOR/
DIRECTOR:		DIMITROVA, DESSIFACILITY TYPE:
740
ADDRESS:2506 CASTLEWOOD DRTELEPHONE:
(916) 486-4265
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 2DATE:
04/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Dessilava DimitrovaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 4/10/2025 a unannounced annual visit made at this facility by Licensing Program Analyst (LPA) Holly Williams and Licensing Program Manager (LPM) Czarrina Camilon-Lee.  This LPA and LPM was met by the Facility Designated Administrators (FDA) Dessislava Dimitrova's mother S1 and father S2.

The FDA Dessislava Dimitrova came to the facility and a brief interview was held with Dimitrova.

Current census was 2 residents.
It was learned that there were (0) residents under the care of hospice at this time.
It was learned that there was (0) resident receiving services through home health at this time.
It was learned that there were (1) residents diagnosed with dementia at this time.

Facility staff files were supplied by the Licensee for review at this time.  This LPA also requested for the facility resident files at this time.


Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured.  Furniture



[Continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Holly Williams
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNNY BEACH VILLA
FACILITY NUMBER: 347004408
VISIT DATE: 04/10/2025
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and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured. LPA observed grime, grease, and a sticky floor through out the kitchen. LPA observed in the drawers in the kitchen an excess amount of napkins, plastic, and the drawers had not been cleaned.

Based on facility sketch room #3 designated as a client room has been changed to a staff room. Similarly, the master bedroom approved for resident room has been changed to a staff room. LPA advised the FDA to correct facility sketch and obtain new fire clearance. Facility resident bedrooms were toured.  LPA observed in R1's room unlocked medications and it states in the LIC 602 that the resident is not allowed to handle their own medication. Facility resident restrooms were toured. Grab bars and non-skid mats in bathroom were observed to be present and in good repair at this time.

Kitchen drawers and cabinets were opened and reviewed.  Knives were observed to be unlocked in the kitchen drawers. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed and were adequate. Food in the refrigerator was not covered.
Laundry area, located in the walkway leading to the outside, was toured.  Bleach, detergent, and all other cleaning supplies were observed to be unlocked and accessible to the residents.
Medication cabinet, was observed to be unlocked and accessible to the residents.
First aid kit, located in the medication area, was reviewed and requested the items to be provided including a manual and scissors. Fire extinguishers (2), located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company Jorgensen, and found to be in compliance at this time. LPA observed bedroom 2 and the staff room did not have smoke detectors. LPA advised the administrator that the 2 smoke detectors need to be replaced because they are missing.

Overall the LPA observed the facility needs a major deep cleaning to include; floor surfaces need to be washed, carpet needs to be replaced, walls, cabinets, windows, and baseboards need to be wiped down.












[Continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Holly Williams
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNNY BEACH VILLA
FACILITY NUMBER: 347004408
VISIT DATE: 04/10/2025
NARRATIVE
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Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted.  A review of the facility perimeter fence, side gates, and all other exits was conducted.  LPA observed tools, rakes, and ladders that were accessible to resident's.
A review of (2) facility resident files was conducted and noted on the following LIC 858.
A review of (2) facility staff file was conducted and noted on the following LIC 859.
The following forms and documents were requested to be updated and submitted to CCL:
LIC 500
LIC 308

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Holly Williams
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2025 03:41 PM - It Cannot Be Edited


Created By: Holly Williams On 04/10/2025 at 11:50 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: SUNNY BEACH VILLA
FACILITY NUMBER: 347004408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 8 out of 8 rooms in the facility were not maintained and clean which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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FDA agrees to conduct a deep clean of the facility with in 2 weeks of the POC due date. FDA agrees to send a plan stating when the cleaning will be done, pictures of end result, and what kind of cleaning by POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above the cleaning solutions were accessible to residents and not locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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FDA will send by POC due date will send a plan of action. FDA will conduct a training for alll employees on medication storage and the training will be 1 hour in length and send LPA Williams the sign in sheet within two weeks of the POC due date. FDA agrees to put a key lock on the outside of the door leading to the laundry room within 1 week of the POC due date.. FDA agrees to install a key lock on the outside of the staff room within 1 week of the POC due date..
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Holly Williams
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2025 03:41 PM - It Cannot Be Edited


Created By: Holly Williams On 04/10/2025 at 11:50 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: SUNNY BEACH VILLA
FACILITY NUMBER: 347004408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above floors were sticky, carpets need to be replaced, and the facility had a very strong cat odor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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FDA agrees to provide a plan to ensure a general clean up is conductedby POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Holly Williams
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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