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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:43:49 PM


Document Has Been Signed on 05/12/2023 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: 105DATE:
05/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Candi BolinTIME COMPLETED:
03:48 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management investigation at the facility. LPA met with facility Administrator Candi Bolin (Admin). Case management was initiated in response to an incident report sent to the department by the facility, which detailed an elopement of a facility resident (R1) that occurred on 02/24/2023.

In interview with facility medical director regarding the details of the elopement, it was determined that the facility became aware of the elopement due to a phone call from R1's responsible person (RP). RP stated that R1 was discovered outside of the community by a pedestrian (W1), who was able to make contact with RP due to R1 having RP's contact information on their person. Review of R1's physician's report indicated that R1 is not permitted to leave the facility unattended. RP picked up R1 and returned them to the facility at approximately 04:00pm. The facility was unable to determine when R1 eloped, but believe that it occurred during peak hours of foot traffic in the facility (12:00pm-1:00pm). Facility had two staff monitoring the facility exit, but did not detect R1 leaving the facility.

In R1's progress notes, it was not noted what time R1 eloped from the facility, Review of R1's progress notes did not yield any information in reference to R1's elopement. Upon return to the facility, R1 was given a wander guard to detect further elopements. Since elopement on 02/24/2023. R1 has not attempted to elope the facility again. The facility has not had any elopement concerns since elopement on 02/24/2023. Facility is currently in the process of front doors being installed with delayed egress devices to prevent future elopements from the facility.

Deficiency has been cited, see 809-D. This report was reviewed with facility Administrator. Advisory notes and signed 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: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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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Document Has Been Signed on 05/12/2023 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 445202756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2023
Section Cited

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Care of Persons with Dementia - (k) The following initial and continuing requirements must be met... (4) ...facility staff shall attempt to redirect a resident who attempts to leave the facility. This requirement is not met as evidence by:
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Resident re-assmenet has been completed and resident has been equipped with a wander guard. Facility to conduct in-service training on elopement policy by POC due date.
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Based on interviews and records review, the licensee did not ensure facility staff attempted to redirect resident (R1) from leaving the facility unassisted which poses an immediate Health and Safety risk to persons 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: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
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