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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601134
Report Date: 12/23/2024
Date Signed: 12/23/2024 08:43:15 PM

Document Has Been Signed on 12/23/2024 08:43 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SUNSHINE CARE HOME FACILITY LLCFACILITY NUMBER:
415601134
ADMINISTRATOR/
DIRECTOR:		ROXANNE EDUARTEFACILITY TYPE:
740
ADDRESS:2976 FLEETWOOD DRIVETELEPHONE:
(650) 720-1441
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver, Rodolfo CastaloneTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On 12/23/2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Rodolfo Castalone and explained the purpose of today's visit. Caregiver called and informed the Licensee, Fe Bret and the administrator, Roxanne Eduarte of LPA's inspection.

LPA toured the facility's building and grounds. This is a two level home. Upper level is for facility care staff and 1st floor is for residents. 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 109-110 degrees F. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

LPA observed sharps, central stored medication, toxins and chemical were locked and inaccessible to residents.

Facility is equipped with smoke detectors and carbon monoxide detectors. .

A review of (6) resident files was conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.

The following documents were requested submitted to CCL by :12/24/2024:
- Administrator Certificate and Liability Insurance.

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 caregiver in person and administrator over the phone.

A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/23/2024 08:43 PM - It Cannot Be Edited


Created By: Murial Han On 12/23/2024 at 11:47 AM
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
, 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: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by: based on observation, record review and interview, the administrator acknowledged that 2 out of 6 resident's file did not have a copy of the reapprasials
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in based on observation, record review and interview, the administrator acknowledged that 2 out of 6 resident's files did not have a copy of the reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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The administrator/licensee will provide a plan to ensure all resident files are complete and readily available to staff and licensing staff. The administrator/licensee will provide a copy of the plan to CCL by 12/30/2024
Type B
Section Cited
CCR
87412(c)
87412 Pesonnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
This requirement is not met as evidenced by: based on records review, observation and interview, training records are missing from personnel records for 4 out of 4 staff members and the administrator acknowledged this observation and stated that training will be provided to LPA/CCL by the end of the day.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above based on records review, observation and interview, training records are missing from personnel records for 4 out of 4 staff members and the administrator acknowledged this observation and stated that a copy of the training records will be provided to LPA/CCL by the end of the day. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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The administrator/licensee will provide a plan to ensure all staff training records are maintained in the personnel records and will provide a copy of the plan to CCL by 12/30/2024.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2024 08:43 PM - It Cannot Be Edited


Created By: Murial Han On 12/23/2024 at 12:03 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
, 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: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above based on record review, observation and interview, 5 out of 6 residents have bedrails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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The administrator will provide a plan in writing to ensure a physician's order is obtained, date it will be obtained and provide a copy of the order on that date to CCL. The administrator will provide a copy of the plan to CCL by 12/24/2024.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
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