415601134-1-17-2024-14-AS-MHAN-CZKSAJ-20240117124224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601134
Report Date: 01/17/2024
Date Signed: 01/17/2024 09:12:52 PM

Document Has Been Signed on 01/17/2024 09:12 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	SUNSHINE CARE HOME FACILITY LLC		FACILITY NUMBER:	415601134
ADMINISTRATOR:	DE LA TORRE, JOCELYN		FACILITY TYPE:	740
ADDRESS:	2976 FLEETWOOD DRIVE		TELEPHONE:	(650) 720-1441
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	01/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Roxanne Eduarte		TIME COMPLETED:	12:55 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	On 1/17/2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with administrator, Roxanne Eduarte and explained the purpose of today's visit. LPA toured the facility's building and grounds. This is a two level home. Upper level is for facility care staff and ground floor is where the residents live. There are 4 bedrooms (2 shared and 2 private) for the residents and 2 full bathrooms. All rooms for residents are non-ambulatory. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 105-108 degrees F. LPA inspected the kitchen and dining room area. Dining room area is observed as clean and in order. Both fresh food and frozen food supplies are inspected and observed as in place in the kitchen. Dry goods/emergency food supplies are in place also being stored in the garage. LPA observed central stored medication, toxins and chemical were locked and inaccessible to residents. LPA observed sharps in the kitchen were unlocked and accessible to residents in care. Facility is equipped with smoke detectors and carbon monoxide detectors. .

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC	FACILITY NUMBER: 415601134
	VISIT DATE: 01/17/2024

NARRATIVE

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LPA reviewed 4 resident records and all of them contained physician's report (LIC 602); however missing admission agreement, appraisal service needs and plan, pre-admission appraisal and safeguards for resident's personal belongings and valuables.

LPA reviewed 3 staff files (one of them is the administrator) and all of them contained personnel records, health screening, First Aide/CPR, fingerprint cleared, however, none the staff members are associated to the facility.

LPA requested documents to update administrator- A written letter from the Licensee appointing the current administrator for the facility, administrator certification, LIC 500, LIC 501 and LIC 308 to be submitted to CCL by 1/19/2024.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/17/2024 09:12 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC	FACILITY NUMBER: 415601134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide any documentation to proof that drills were conducted per the regulation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will conduct a drill immediately and provide staff training sign-in sheet to CCL along with a plan to ensure drills will be conducted accordingly moving forward.

Type A

Section Cited

CCR

87705(f)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as sharps in the kitchen were not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and in-service staff.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/17/2024 09:12 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC	FACILITY NUMBER: 415601134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 4 residents did not have an admission agreement and 4 out of 4 residents did not have a pre-placement appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will ensure all the admission agreement and pre-admission appraisals are completed and provide a copy to CCL by 1/24/2024.

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 4 residents did not have documents to proof that this process has been completed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 1/24/2024.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/17/2024 09:12 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC	FACILITY NUMBER: 415601134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(g)(2)

This requirement is not met as evidenced by: S1, S2 and new administrator are not associated with the facility.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1, S2 and new administrator are not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2024
	Plan of Correction
1 2 3 4	The administrator will provide a plan by 1/18/2024 to ensure all staff are associated with the facility and will provide proof in one week that staff are associated.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 01/17/2024 09:12 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC	FACILITY NUMBER: 415601134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87217(b)

This requirement is not met as evidenced by: Safeguards for Personal Property and Valuables
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 4 residents did not have proof that facility has documented their personal property and valuables which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and provide a copy of the safeguards personal property and valuables form (LIC613) to CCL along with the plan by 1/24/2024.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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