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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 04/04/2025
Date Signed: 04/04/2025 11:42:50 AM

Document Has Been Signed on 04/04/2025 11:42 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
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:
04/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Administrator Candace BolinTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a Case Management-Incident regarding 2 elopements that occurred on 12/8/2024 and 12/15/2024. LPAs met with Administrator Candace Bolin and stated the purpose of the visit.

Elopement 12/8/2024
On 12/11/2024 the Department received an incident report for Resident R1, who eloped from the facility on 12/8/2024. The incident report stated: "Door 1 alarmed at 11:11 AM, Care giver looked out the window of Garden house and saw the resident walking outside. Staff Went out to escort resident back inside and the resident was no longer in site. Staff immediately initiated a search of the surrounding neighborhood...911 was called and police assisted with search...Police escorted resident back to the community at 12:20 PM. Police officer reports that the resident walked in the police station."

On 12/11/2024 LPA Simi Rai spoke with ADM regarding the incident report of R1's elopement on 12/8/2024. ADM stated that the whole building has delayed egress doors except for one door, which R1 found and exited the facility from during the incident. ADM stated the door located on the main floor in the stairwell had an alarm and not a delayed egress. The facility has four floors with the memory care unit is the in the basement. ADM stated R1 has neurocognitive disorder. ADM stated R1 cannot leave the facility unassisted. R1 was found by the police when R1 entered the police department down the street from the facility.

Based on a Google Maps search the Police Department is located 0.4 miles from the facility
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NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/04/2025
NARRATIVE
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On 12/19/2024, LPAs Marcella Tarin and Kenneth Madrigal interviewed the Administrator (ADM). ADM stated R1 does not have exit seeking behaviors and no history of wandering. ADM stated R1 has not expressed he/she wants to leave the facility, and resident does not have recollection of leaving the facility.

LPAs Marcella Tarin and Kenneth Madrigal interviewed staff, S1-S2. Staff S1 stated, R1 often shows wandering behavior by the front door. S1 stated every day, R1 by the door looking out the door wanting to leave.

On 2/20/2024 LPAs Marcella Tarin and Manuel Monter interviewed 11 staff (S3-S13). 6 out of 11 (S3-S6, S12, S13) staff stated R1 has wandering behaviors. 5 out of 11 (S7-S11) staff stated he/she does not know if R1 has wandering behaviors.

Based on review of R1's service plan dated 12/06/2024 under Evaluation Item, Evaluation Section: Psychosocial: Wandering, states resident has a current or history of wandering within the residence or facility and may wander outside. R1’s physician’s report dated 5/9/2024 lists R1’s diagnosis as neurocognitive disorder. R1’s mental condition as confused/disoriented, has wandering behaviors and R1 cannot leave the facility unassisted.

Elopement 12/15/2024

On 12/18/2024, the Department received an Incident Report regarding Resident R2 eloping from the facility on 12/5/2024. R2 was returned to the facility by local police that same day and was unharmed during the elopement.

On 12/19/2024, LPAs Marcella Tarin and Kenneth Madrigal interviewed the Administrator (ADM). ADM states R2 wears a Wanderguard and has exit seeking behavior. ADM stated the facility was not aware R2 had eloped from the facility until police informed the facility that R2 was found at a grocery store, Trader Joes.



Based on a Google Maps search, R2 was located 0.9 miles from the facility.

On 2/20/2024 LPAs Marcella Tarin and Manuel interviewed Administrator (ADM) ADM stated R2 has eloped from the facility in the past but could not provide a date.
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NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
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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: 04/04/2025
NARRATIVE
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LPA’s interviewed 11 staff (S3-S13). 8 out of 11 (S3-S9, S12) staff stated R2 has wandering behaviors, and 4 out of the 8 (S7-S9, S12) staff state R2 has eloped or attempted to elope from the facility in the past. 3 out of 11 (S10, S11, S13) staff state they are not aware of R2 eloping from the facility of having wandering behaviors.

Staff S6 stated the facility has a list of residents who can leave unassisted. S6 stated if a resident who can’t leave the facility unassisted tries to leave the facility, staff will redirect. Staff S6 acknowledged that resident R2 likes to come to the front door, but staff will redirect.

On 4/5/2025 LPAs interviewed ADM. ADM stated staff at the front desk have a list of residents (with pictures) who can leave the facility unassisted.

Based on evidence reviewed, on December 5, 2024, R2’s service plan dated 9/23/2024 under Evaluation Item, Evaluation Section: Psychosocial: Wandering, states resident has a current or history of wandering within the residence or facility and may wander outside. R1’s physician’s report dated 2/7/2023 lists R1’s diagnosis as neurocognitive disorder. R1’s mental condition as confused/disoriented, has wandering behaviors and R1 cannot leave the facility unassisted.

Based on evidence reviewed, R2 walked out of the lobby’s front door by following an individual who was exiting the facility on 12/5/2024.

As a result, the department issued an immediate civil penalty of $500 for an absence of supervision, which resulted in R1 and R2 eloping from the facility.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Administrator Candace Bolin and a copy of the report was provided. Appeal Rights was provided.

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NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 11:42 AM - It Cannot Be Edited


Created By: Marcella Tarin On 04/04/2025 at 10:31 AM
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: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2025
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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ADM stated facility has installed egress doors, the facility will conduct on-going elopement training and elopement drills, and ensuring front desk staff re-direct residents. ADM will submit the Plan of Correction (POC) of planned staff training to the Department by 4/5/2025.
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Based on record review and interviews, R1 and R2 cannot leave the facility unassisted. Both residents left the facility unassisted and were returned back to the facility by local law enforcement, which poses an immediate health, safety and personal rights risks to residents in care.
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Type A
04/04/2025
Section Cited
CCR87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision... delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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ADM stated the facility will conduct on-going elopement training and elopement drills, and ensuring front desk staff re-direct residents and call for help with re-directing residents. ADM will submit Plan of Correction (POC) of planned staff to the Department by 4/5/2025.
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Based on interviews, the facility staff did not re-direct R1 and R2 when they eloped from the facility. Facility staff were also unaware that R2 had eloped from the facility, which poses an immediate health, safety and personal rights risk to resident 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.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
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