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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:43:43 PM


Document Has Been Signed on 07/20/2022 03:43 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
CENTRAL COAST CR/RES, 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: 101DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Candi BolinTIME COMPLETED:
03:40 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 07/20/2022 at 02:28pm. LPA met with Administrator Candi Bolin (Admin).

Sign with visitor policy was posted at the facility entrance. LPA toured the facility, including courtyard, library, activity room, dining room, kitchen, office, billiard's room, meeting room, 10 resident bedrooms, and 12 bathrooms. All staff members observed to be wearing masks upon entrance into the facility. Admin confirmed that all staff and all but two residents have been vaccinated.

No prohibited items noted in resident rooms. All bedrooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available in facility bathrooms. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to have been inspected in November of 2021. All cleaning supplies and chemicals noted to be in locked cabinets and closets.

Facility observed to have a designated entry point. Staff took LPA's temperature and screened for symptoms. 30 days supply of PPE was observed. Hand washing signs were observed in the facility bathrooms. Water temperature observed to be 109.7 *F. Social distancing signs observed to be posted in all public areas. Facility temperature observed to be 73 degrees Fahrenheit.

No deficiencies cited during today's visit. Report was reviewed with Administrator Candi Bolin and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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