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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 03/20/2025
Date Signed: 03/20/2025 02:08:24 PM

Document Has Been Signed on 03/20/2025 02:08 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: 107DATE:
03/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:General Manager, Candace BolinTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error. LPAs met with General Manager (GM) Candance Bolin and stated the purpose of the visit.

On 3/4/2025 the Department received an Incident Report for a medication error of Resident R1 that occurred on on 2/27/2025. The incident report states: "On Thursday, February 27th. It was reported that the Staff S1 administered two doses of Medication (referred to as M1) to resident R1. The medication order specified 10mg of M1 to be given at 4:00PM and 8:00PM. M1 was supplied in syringes as 10mg/5mL. However, two syringes were administered during each scheduled time, resulting in the resident receiving a total of 20mg at 4PM and another 20mg at 8PM. This is confirmed by the med tech (referred to as staff S1) signatures and sign-out on the record. indicating the admin of 2 syringes at both 4PM and 8PM and the M1 count, showing 2 additional syringes being removed...S1 will undergo retraining on medication administration, focusing on dosages calculation, concentration awareness and the importance of double-checking orders...and an inservice will be provided to all Med techs on Medication errors and their prevention."

LPAs interviewed Health Services Director (HSD), who stated Staff S1 admitted to giving two doses of M1 to R1 on 2/27/2025. HSD states S1 did not conduct the required medication checks before administering M1 to R1.

A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with General Manager, Candace Bolin and a copy of this report was provided. Appeal rights were also provided.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 03/20/2025 02:08 PM - It Cannot Be Edited


Created By: Marcella Tarin On 03/20/2025 at 01:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2025
Section Cited
CCR
87411(a)

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

This requirement was not met as evidenced by
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Administrator stated the facility conducted an in-service for staff on medication training on 2/28/2025.

ADM provided documentation of in-service training conducted on 2/28/2025.
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Based on investigation, on 2/27/2025, Staff S1 administered 2 incorrect doses of medication M1 to R1 which poses an immediate health, safety and personal rights 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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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