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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 10/24/2023
Date Signed: 10/26/2023 08:06:19 AM


Document Has Been Signed on 10/26/2023 08:06 AM - It Cannot Be Edited

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: 90DATE:
10/24/2023
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Candi BolinTIME COMPLETED:
11:59 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - Incident visit and met with General Manger (GM) Candi Bolin and Health Services Director (HSD) Daris Duong.

LPA addressed the purpose of today's visit to GM and HSD. On 10/06/2023, the Department received a notice from the facility that a resident (R1) left the facility without notice on 10/01/2023. R1 was brought back to the facility by the spouse on the same day.

LPA interviewed 3 staff (HSD, S1, S2). LPA toured R1's bedroom with HSD, R1 was took out with R1's spouse at 9:30AM today. LPA reviewed documents with HSD.

Deficiencies were noted today. LIC809-D was provided.

Exit interview was conducted with GM and HSD. The reports were provided to GM and HSD for signature. A copy of the reports was provided to GM and HSD.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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 10/26/2023 08:06 AM - 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
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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2023
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidenced:
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General Manager stated the facility to submit a plan of correction on how to prevent future elopement to happen in the facility for all residents.
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Based on the interviews and documents reviewed, resident R1 left the facility without notice, and R1 was brought back to the facility after 6:00PM on the same day.
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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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2