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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004408
Report Date: 11/17/2021
Date Signed: 11/17/2021 03:53:30 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/17/2021 03:53 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNNY BEACH VILLAFACILITY NUMBER:
347004408
ADMINISTRATOR:DIMITROVA, DESSIFACILITY TYPE:
740
ADDRESS:2506 CASTLEWOOD DRTELEPHONE:
(916) 486-4265
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 3DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:ADMINISTRATOR - DESSI DIMITROVATIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced annual required visit on 11/17/2021 at 12:30 PM. LPA met with the Administrator and explained purpose of the visit.
LPA toured the facility and inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA observed the Fire extinguisher expired on 09/11/2021 and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present and in working order.
LPA observed centrally stored medications, knives and toxins locked and not accessible to residents. LPA reviewed 3 resident and 3 staff files, including criminal record clearances. All staff today are Fingerprint cleared and associated to the facility. First aid/CPR certificates are current. First aid kit was checked and is complete.
The following documents needed to be submitted to licensing by January 11, 2022:
Admissions Polices and Procedures, Control of Property - Lease, Health Screening Report -Copy, Job Descriptions/Personnel Policies, Liability Insurance, Plan for Incidental Medical and Dental Care, Plan of Operation, Theft and Loss Policy and Procedures, Transportation Procedures, Administrator Certificate, and a copy of Liability Insurance
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited. See 809-D for citation. Immediate civil penalty of $500.00 was issued to facility. Failure to correct the deficiency by the noted due date may result in an additional penalty being assessed.
Exit interview held and a report left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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 11/17/2021 03:53 PM - It Cannot Be Edited


Created By: Ruth Wallace On 11/17/2021 at 01:47 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNNY BEACH VILLA
FACILITY NUMBER: 347004408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
87202(a)

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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:
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LIcensee agreed to purchase a new fire extinguisher while LPA Wallace was at facility on 11/17/2021. New Fire Extinguisher was purchased and no further action was required. An immediate civil penalty of $500.00 was issued to facility.
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Based on LPA observation the Fire Extinguisher expired 09/11/2021, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons 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 Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021


LIC809 (FAS) - (06/04)
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