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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802283
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:33:50 PM

Document Has Been Signed on 08/31/2023 01:33 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HOBSON SONSHINE HOMEFACILITY NUMBER:
405802283
ADMINISTRATOR:HOBSON, NANCYFACILITY TYPE:
735
ADDRESS:12105 EL CAMINO REALTELEPHONE:
(805) 461-1437
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 6DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Julia Hawke, LicenseeTIME COMPLETED:
01:50 PM
NARRATIVE
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On 8/31/23 at 10:05 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced Annual/Required visit to the facility listed above. LPA met with Julia Hawke, Licensee, and explained the purpose of the visit. Also in attendance was Miguel Magana, Quality Assurance Specialist, Tri-Counties Regional Center.

LPA toured the facility with the licensee and quality assurance specialist. There was one client in the facility during the visit. Licensee states the remaining clients are at day program. The facility is maintained in conformity with state fire marshal regulations. The smoke detectors and carbon monoxide detector were tested and functioning properly. The fire extinguisher was located in the locked laundry room. The extinguisher was fully charged, however, the most recent inspection was on 11/30/21. Licensee will get a new inspection or new fire extinguisher and send LPA a copy of the new inspection tag or receipt by 9/7/23. There are no pools. There was a water fountain outside the facility, however, there was no water in the fountain. There are no firearms or dangerous weapons stored. Hot water temperatures were recorded in the kitchen and resident bathrooms. Temperatures registered between 114.2 F and 114.9 F degrees. All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The facility is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees, and visitors. Two exceptions are that the screen on the sliding glass door has three tears in it, approximately 4 inches long. Licensee will repair or replace the screen and send photos to LPA by 9/7/23. The other exception is that the oven has food splatters and needs cleaning. Licensee will clean and send photo to LPA by 9/7/23. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. There is a minimum 2-day supply of perishables and 7-day supply of nonperishable foods. Food is stored and prepared in a safe and healthful manner. Disinfectants and cleaning solutions are inaccessible to clients. However, there is a shed on the property that is unlocked containing tools and toxins. The shed is accessible to clients. Deficiency cited.

Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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 08/31/2023 01:33 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/31/2023 at 01:06 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOBSON SONSHINE HOME
FACILITY NUMBER: 405802283

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the unlolcked shed on the property contained tools and toxins which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Licensee has agreed to place a lock on the shed and send a photo to LPA by the due date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in one out of five staff files reviewed indicate missing TB results which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Licensee has agreed to get TB results on staff missing results and will send copy of results to LPA by 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2023 01:33 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/31/2023 at 01:06 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOBSON SONSHINE HOME
FACILITY NUMBER: 405802283

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in one out of five staff files reviewed indiacate missing first aid certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Licensee has agreed to obtain first aid certification on staff missing certificate and will send to LPA by the 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOBSON SONSHINE HOME
FACILITY NUMBER: 405802283
VISIT DATE: 08/31/2023
NARRATIVE
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The facility has adequate emergency supplies and first aid supplies. Facility temperature is 75 F degrees. Outdoor walkways are free from obstruction and the facility has an outside covered patio area for individuals to use. The facility has resident rights, CCLD complaint poster, non-discrimination statement, and emergency disaster plan posted, however, they were posted in the locked laundry room. Licensee will post in a common area and send LPA a photo by 9/7/23.

LPA reviewed (5) staff files for criminal record clearances and associations, Health screening with TB results, and current First Aid/CPR. One out of five staff files reviewed indicate missing TB results. Deficiency cited. One out of five staff files reviewed indicate missing CRP/First Aid results. Deficiency cited.

Emergency disaster drills are conducted quarterly.

LPA reviewed five (5) client files for current health records, needs and services plans, signed admission agreements and personal rights. All client files are complete and in-compliance.

Clients’ centrally stored medications are kept in a locked cabinet in the kitchen. Medications are given as prescribed by doctors’ orders.

Exit interview conducted, deficiencies cited, and the report and appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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