445202756-7-18-2024-26-AS-MMOR-D7B22U-20240718170119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 07/18/2024
Date Signed: 07/18/2024 05:01:32 PM

Document Has Been Signed on 07/18/2024 05:01 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 CARE		FACILITY NUMBER:	445202756
ADMINISTRATOR:	MCKIE, JAMES		FACILITY TYPE:	740
ADDRESS:	80 FRONT STREET		TELEPHONE:	(831) 459-8400
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	132	CENSUS: 94	DATE:	07/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Head Nurse Sharon Carollo		TIME COMPLETED:	05:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff S1, Hilda Bejar. During the visit, S1 stated there are 88 residents in Assisted Living and 6 residents in Memory Care. Staff S1 stated facility Administrator is on vacation. LPA toured the facility inside out with staff S1, which included the 1st-4th floor, including the basement, which is being used as memory care. LPA and S1 also toured the kitchen, dining room, activity room, restrooms and residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 114 degrees F in resident bathrooms. Fire extinguisher was serviced in September 6, 2023. The facility was equipped with smoke and carbon monoxide detectors. Sprinkler system last maintenance was on June 27, 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 5/18/2024. LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed resident R1's medications, while cross referencing the Centrally Stored Medication Log, LPA observed the medication start date for medications M1-M7 was not listed in the centrally stored medication log. LPA reviewed resident R2's medications, while cross referencing the centrally stored medication log. LPA observed the medication start date for medications M1-M4 was not listed in the Centrally Stored Medication Log. Page 1 Out of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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
	VISIT DATE: 07/18/2024

NARRATIVE

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LPA conducted interviews with 3 staff and 3 residents.

While reviewing resident R3’s file, LPA observed a physician fax communication. The form stated R3 had a fall, June 1st, 2024, and was sent out to the emergency room. Staff S1 showed LPA incident tracking log on his/her computer. The log stated the responsible party was contacted, R3's physicians was contacted, and a text was sent to the ADM. Under the section, "Reported to State", the website states no. (Photographs were taken.) Staff S1 contacted facility ADM via phone call, (at 1:30pm), and ADM stated he/she did send an incident report. ADM stated a fax confirmation is in her office. ADM stated she will try to get someone to find the fax confirmation received form. LPA was not given documentation that the incident report was sent to CCL by the end of the annual inspection visit.

While touring the facility, LPA observed resident R2's bedroom has quarter sized bed rail. While reviewing R2's records, LPA did not find a doctors order for the bed rails. Staff S2 stated he/she has been working on it with the doctor. Staff S2 reviewed R2's file to find the doctors order but could not provide LPA with the doctors order. Staff S2 stated he/she would send LPA documentation for the bed rails.

Deficiencies cited during today's visit. This report was reviewed with S2 Sharon Carollo. A copy of the signed report was provided. Appeal Rights were provided

Page 2 Out of 2.

END OF REPORT

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/18/2024 05:01 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: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)

Reporting Requirements

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Based on record review, R3 had a fall on June 1, 2024. LPA requested to see documentation showing an incident report was sent to Community Care Licensing. The facility was unable to show documentation showing they submitted an incident report to Community Care Licensing. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	ADM stated she will send a letter of understanding regarding the regulation and the importance of reporting requirements. ADM stated she will send the letter by POC date, July 25, 2024.

Type B

Section Cited

CCR

87465(h)(6)

87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & record review, the licensee did not comply with the section cited above. LPA observed the medication start date for medications M1-M7 was not listed in the centrally stored medication log for resident R1. LPA observed the medication start date for medications M1-M4 was not listed in the Centrally Stored Medication Log for R2. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	ADM stated she will conduct a medication training and send LPA documentation the training has taken place.

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 Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3