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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004408
Report Date: 08/16/2024
Date Signed: 08/16/2024 03:09:46 PM

Document Has Been Signed on 08/16/2024 03:09 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:
08/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Dessi DimitrovaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to Sunny Beach Villa RCFE on DATE at TIME to conduct a case management inspection to address deficiencies observed during a complaint investigation. LPA Gould met with Licensee, Dessi Dimitrova and together discussed the details of the case management.

The department has determined, while conducting a complaint investigation, that the facility did not seek timely medical attention for a former resident. The department reviewed former resident’s medical records and observed the resident was admitted to the hospital on 5/18/23 with open wounds and bone protrusion on bilateral toes. Two primary caregivers interviewed denied ever witnessing resident’s toes/feet being in the condition shown and described by investigators. Previous statements obtained from caregivers stated that they assisted resident with putting on shoes without socks the date resident was admitted to the hospital and assisted the resident with bathing twice a week. Medical records indicate the resident or facility staff did not seek medical attention from the last visit in February 2023 until resident was admitted to the hospital and passed away on 5/18/23.

The department has determined the facility staff did not to seek medical attention in a timely manner for resident’s foot injury.

Per the California Code of Regulations, Title 22 the following deficiency is cited. Due to the injury and subsequent deficiency, an immediate civil penalty is issued today. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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 08/16/2024 03:09 PM - It Cannot Be Edited


Created By: Kevin Gould On 08/16/2024 at 02:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNNY BEACH VILLA
FACILITY NUMBER: 347004408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2024
Section Cited
CCR
87465(a)(1)

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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by Photographic evidence and statements from medical
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The Licensee has agreed to incorporate a body/skin check to be filled out during each resident's showering day where staff will inspect and document any changes in condition. Licensee will provide a written plan of correction detailing how the facility will implement the body checks and when to contact physician or seek medical attention.
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personnel that R1 was admitted to the hospital with two open wounds on toes with bone protrusion and did not seek medical attention for R1’s wounds in a timely manner which poses an immediate health, safety and personal rights 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
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