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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202292
Report Date: 07/16/2020
Date Signed: 07/16/2020 02:26:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SUNSHINE VILLA ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
445202292
ADMINISTRATOR:JAMES MCKIEFACILITY TYPE:
740
ADDRESS:80 FRONT STREETTELEPHONE:
(831) 459-8400
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:132CENSUS: 117DATE:
07/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Craig Cady, Health Services DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Anna Bui conducted an unannounced case management – incident visit. Due to current COVID-19 situation, LPA did a Tele-Visit via facetime with Craig Cady, Health Services Director (HSD).

On 6/5/2020, the Department received an Unusual Incident Report regarding missed medications. The incident occurred on 5/22/2020 but was not received by the Department until 6/5/2020. The reason for the missed medications was due to a staff shortage: two med techs were out due to COVID-19 precautions that require anyone ill to not return to work until 72 hours symptom-free. Craig Cady stated the reason for the late reporting was due to him having to gather more information about which clients missed the medications.

There was another late reporting for an incident that occurred on 3/11/2020 but was not received by the Department until 4/3/2020. HSD did not have a reason for the late reporting.

Due to COVID-19 pandemic, no deficiency was cited during the visit. However, an advisory note was issued for the late reporting.

This report was reviewed with HSD Craig Cady and was emailed to HSD on 7/16/2020 for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna BuiTELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020
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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