445202756-7-10-2020-26-AS-ABUI-BRDV2P-20200710160328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 07/10/2020
Date Signed: 07/10/2020 04:04:12 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 CARE		FACILITY NUMBER:	445202756
ADMINISTRATOR:	MCKIE, JAMES		FACILITY TYPE:	740
ADDRESS:	80 FRONT STREET		TELEPHONE:	(831) 459-8400
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	132	CENSUS: 106	DATE:	07/10/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	James "Jim" McKie		TIME COMPLETED:	04:00 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	Licensing Program Analysts (LPAs) Anna Bui and Jackie Jin conducted a Pre-licensing Tele-Visit due to COVID-19 health pandemic. LPAs met with James “Jim” McKie, Executive Director via facetime. The application is a change of ownership. The facility has a fire clearance approved for 132. The facility currently has 106 residents. LPAs toured the facility inside and outside including the resident apartments, bathroom, kitchen, and common areas. Resident apartments were observed with proper furniture such as a bed, chair, dressers, lamps, and adjustable thermostat to a comfortable temperature. Beddings and linens were observed available for the residents. Common area was observed with proper furniture and activities available for the residents. Bathroom is equipped with grab bars and nonskid strip. Hygiene items and toiletries are available. Hot water temperature was measured for 14 resident bathrooms, range between 105-119 degrees Fahrenheit. Facility temperature was maintained at 72 degrees Fahrenheit. Centrally stored medications, sharp objects, cleaning supplies, and toxins were locked and inaccessible to the residents. First aid kid was observed complete with all necessary supplies. Facility has a laundry unit with laundry supplies available. At least 2 days worth of perishables and 7 days worth of nonperishable were observed. Kitchen area was observed clean and sanitary. Refrigerator temperature is maintained at 35 degrees Fahrenheit and freezer temperature is maintained at -2 degrees Fahrenheit. Continue on page 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 445202756
	VISIT DATE: 07/10/2020

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
26
27
28
29
30
31
32

Facility is equipped with smoke detectors and carbon monoxide detector. Fire extinguisher was last serviced on September 11, 2019. Hallways and passageways were free of obstruction.

LPAs requested the following documents: Dementia Plan of Operation, Liability Insurance, 10 staff records containing criminal record clearance (LIC 508) or exemption, 10 resident files containing pre-admission appraisal, physicians report (LIC 602), admission agreement, and a copy of the resident roster by 7/14/2020.

LPA will conduct another Tele-Visit to complete the Pre-licensing visit.

This report was reviewed with James “Jim” McKee, Executive Director. A copy of this report was emailed to James “Jim” McKee, Executive Director on 7/10/2020 for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2