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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881227
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:59:29 PM

Document Has Been Signed on 02/22/2023 12:59 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SUNSHINE BOARD AND CARE IIFACILITY NUMBER:
361881227
ADMINISTRATOR:NOFAL, YUSEFFACILITY TYPE:
735
ADDRESS:1203 N. IRIS LANETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 10CENSUS: 7DATE:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Marylou Virata, Nutrition StaffTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts, Amber Coleman, (LPA Coleman) and Amy Goldenberg, (LPA Goldenberg) arrived to the Sunshine Board and Care II to conduct a Case Management visit to address deficiencies observed during the annual inspection on 12/23/2022. At approximately 2:05 PM, LPA observed an IV Pole attached to Resident #1, (R1) while seated on the couch. LPA inquired about the resident's status. Staff reported that R1, was discharged from the hospital with an IV treatment. LPA was also informed that the IV treatment was being monitored by a home health agency.

While interviewing the Administrator, Mr. Hamed. R1 was taken to a doctor appointment. During the doctor appt. R1 had a medical emergency which resulted in them being transported to the hospital to be admitted. R1 was admitted to the hospital on 12/17/22 and discharged on 12/23/22. LPA inquired if staff submitted their Special Incident Report (SIR) to report the transfer. Administrator stated, staff did not submit an SIR. LPA confirmed, no incident reports had been submitted to the community care licensing office.

Based on observations, collected documents and interviews made during today's visit and the visit on 12/23/22. Two (2) deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations, (CCR). An exit interview was conducted and a copy of this report, LIC809D, was provided to Facility Representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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 02/22/2023 12:59 PM - It Cannot Be Edited


Created By: Amber Coleman On 02/22/2023 at 12:16 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUNSHINE BOARD AND CARE II
FACILITY NUMBER: 361881227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited
CCR
80090(c)

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80090 Health and Safety Services
(c) The Department may grant an exception allowing acceptance or retention of a client who has a medical or health condition not listed in Section 80092 if all of the following requirements are met:
(1) Either the condition is chronic and stable, or it is temporary in nature and is expected to return to a condition normal for that client.
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Licensee agrees to read and review the 80090 Health and Safety Services regulation. Licensee agrees to write a statement of understanding which illustrates the regulation is understood and will be applied in the future. This statement of understanding is to be submitted to Community Care Licensing Office by 3/8/23
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Based on observation, interviews and record review, the licensee failed to obtain an appropriate exception that would allow the acceptance of the resident. Although the facility me the requirement. Licensee failed to seek proper exception; which poses a potential Health, Safety or Personal Rights risk to persons in care.
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Type B
12/23/2022
Section Cited
CCR80061(b)(1)(E)(1)

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80061 Reporting Requirements - Upon the occurrence, during the operation of the facility, of any of the events specified a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Licensee agrees to read and review the 80061 Reporting Requirements- Licensee agrees to write a statement of understanding which illustrates the regulation is understood and will be applied in the future. This statement of understanding is to be submitted to Community Care Licensing Office by 3/8/23
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Based on records review and interviews, the licensee failed to submit a Special Incident Report reporting that the resident was transported to the hospital and admitted.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
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