445202292-9-2-2020-26-AS-SYIP-BTCP6N-20200911110237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202292
Report Date: 09/02/2020
Date Signed: 09/02/2020 04:03:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2020 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20200603140222

FACILITY NAME:	SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	445202292
ADMINISTRATOR:	JAMES MCKIE		FACILITY TYPE:	740
ADDRESS:	80 FRONT STREET		TELEPHONE:	(831) 459-8400
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	132	CENSUS: 95	DATE:	09/02/2020
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	James McKie, Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff not properly trained on medication procedures

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Anna Bui and Jackie Jin conducted a Tele-visit due to COVID-19 health pandemic to deliver the findings to the above allegation. LPAs spoke with James McKie, Executive Director, via facetime.

Between 6/11/2020 and 7/20/2020, six staff members were interviewed. 6 out of 6 confirmed they have received medication training. 5 out of 6 stated they have not pre-poured medications. 6 out of 6 have confirmed that pre-pouring medications are not allowed at the facility.

Continued on page 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200603140222

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 445202292
	VISIT DATE: 09/02/2020

NARRATIVE

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Between 7/29/2020 and 8/5/2020, five residents were interviewed. 5 out of 5 stated that they are receiving their medications on time and have not seen medications being poured for other residents. 5 out of 5 have stated that staff bring them their medications to their room.

A medication pass was also observed for four residents. Med carts were locked, and medications were documented on the computer after they were given. Medications were prepared at each resident’s door and given to the resident in the room or in front of the door. No medications were observed to be pre-poured.

The Medication Training Manual was reviewed and stated “Under no circumstance is a Med Aide allowed to: Give medications poured by another person, pour medications for another person to give, pre-pour medications.” The Plan of Operation also stated “Do not open/prepare medication until resident is ready to accept it.”

Staff files were also reviewed for five Med Techs. Based on interviews and review of staff files, 5 out of 5 staff have the required initial medication training requirements and annual required training hours for 2019.

This Department has investigated the above allegation. Based on interviews, observation, and record reviews, the Department has determined that the allegation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with James McKie, Executive Director, and a copy of this report will be emailed to James McKie, Executive Director, on 9/2/2020 for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2020

LIC9099 (FAS) - (06/04)

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