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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 07/22/2021
Date Signed: 07/23/2021 02:23:56 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:
445202756
ADMINISTRATOR:MCKIE, JAMESFACILITY TYPE:
740
ADDRESS:80 FRONT STREETTELEPHONE:
(831) 459-8400
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:132; 132; 132CENSUS: DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Tami OjwangTIME COMPLETED:
03:18 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 07/22/2021 at 12:11pm. LPA met with facility Administrator Tami Ojwang (Admin). LPA toured the facility, including front office, medicine room, dining room, garden room, mansion, activities room, laundry room, salon, 2 bathrooms, courtyard, 3 resident rooms, and 3 resident bathrooms.

All staff members observed to be wearing masks. Admin confirmed that all but 2 residents and 5 staff members have been vaccinated. Facility policy has been updated to only employ vaccinated staff by August 1st. Facility Mitigation plan has already been submitted and approved. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility noted to possess a 30-day supply of PPE.

Facility observed to have designated entry point. Staff took LPA's temperature, and screened for symptoms. All restrooms stoked with paper towers. Hand washing signs observed in all bathrooms. Social distancing signs not observed to be posted throughout facility in all public areas. All bathrooms observed to have lidded trash cans.

LPA observed water temperature in 3 resident bathrooms. After approximately 2 minutes of heating up, 1 resident room observed to have hot water temperature of 136.4*F, while 1 additional resident restroom noted to have hot water temperature of 140.3*F.

Advisory notes issued and deficiency cited. See 809-D. This report reviewed with Administrator Tami Ojwang and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2021
Section Cited

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87303 (2) - Maintenance and Operation - Faucets used by residents for personal care shall deliver hot water... hot water used by residents to attain a temperature of... not more than 120 degree F. This requirement was not met as evidenced by:
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Based on observation, hot water temperature from sinks in resident restrooms exceeded 120 degrees F. This posed a potential risk to the personal rights and safety of residents in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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