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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:07:02 PM

Document Has Been Signed on 12/19/2024 03:07 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/
DIRECTOR:		BOLIN, CANDACEFACILITY TYPE:
740
ADDRESS:80 FRONT STREETTELEPHONE:
(831) 459-8400
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY: 132CENSUS: 105DATE:
12/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Candance Bolin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced Case Management visit to follow up on two incident reports involving two elopements. LPAs met with Administrator Candace Bolin and explained the purpose of the visit.

On 12/11/2024, the Department received an Incident Report regarding resident R1 eloping from the facility on 12/08/2024. R1 was returned back to the facility by local police and was unharmed during the elopement. On 12/18/2024, the Department received a second Incident Report regarding resident R2 eloping from the facility on 12/15/2024. R1 was returned to the facility by local police and was unharmed during the elopement.

LPAs toured the interior and exterior of the facility and inspected the alarm panel in the Garden House Medroom for 13 alarmed exit doors in the facility. 13 out of 13 doors were alarmed, with all buttons on the panel indicating that the doors were alarmed. LPAs inspected Garden House Door #1 and Stairwell Exit Door #3, and Garden House Gate.

LPAs interviewed 3 staff, and attempted to interview 2 residents during visit. LPAs requested R1 and R2's needs/service plan, R1 and R2's physician's report, staffing roster for 12/08/2024 and 12/15/2024, maintenance service records, a copy of security video footage and resident roster.

Due to insufficient information, this investigation requires additional review.

This report was reviewed with Administrator Candace Bolin and a signed copy of the report was provided.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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