370804662-11-9-2023-08-AS-AROS-CXF2Y6-20231109164812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370804662
Report Date: 11/09/2023
Date Signed: 11/09/2023 04:48:27 PM

Document Has Been Signed on 11/09/2023 04:48 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	SUNSHINE CARE HOME		FACILITY NUMBER:	370804662
ADMINISTRATOR:	FRANCIS GRACE REYES		FACILITY TYPE:	740
ADDRESS:	11812 LAKESIDE AVENUE		TELEPHONE:	(619) 561-0161
CITY:	LAKESIDE	STATE: CA	ZIP CODE:	92040
CAPACITY:	21	CENSUS: 16	DATE:	11/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	Grace Rayes, Administrator		TIME COMPLETED:	04:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Administrator Frances Grace Reyes, after identifying themselves and stating the purpose of the inspection. This facility serves twenty-one (21) residents 60 and above; twelve (12) ambulatory and (9) non-Ambulatory. LPA was accompanied by Administrator’s Ian Baylon and Administrator Grace Reyes during a tour of the facility. There are two (2) separate buildings at the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. PPE supplies are onsite. No bodies of water are on premises. Passageways were free from obstructions. According to Administrator Reyes, there are no weapons and/or ammunition stored on the premises. All doors were operational. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are locked in a storage room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and Non-skid pads. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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 11/09/2023 04:48 PM - 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSHINE CARE HOME	FACILITY NUMBER: 370804662
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Administror Baylon and LPA agree that all staff will get current first aid/CPR certifited within 30 day.

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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSHINE CARE HOME	FACILITY NUMBER: 370804662
	VISIT DATE: 11/09/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Staff records review verified that all staff records were not complete and compliant. All the direct care staff did not have current First Aid certificates and/or First Aide/CPR certificates.

Resident records reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted with Administrator Baylon and Administrator Reyes, to whom copies of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to Administrator’s Baylon and Reyes.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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