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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 10/01/2020
Date Signed: 10/01/2020 04:25:58 PM

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:132CENSUS: DATE:
10/01/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Craig CadyTIME COMPLETED:
04:22 PM
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Licensing Program Analysts Ryker Heberle and Jackie Jin (LPAs) met with Health Services Director Craig Cady (HSD) in order to conduct an unannounced case management tele-visit to review a self-reported Death Report.

LPAs interviewed HSD regarding the incident. Per HSD the incident occurred at another facility that they evacuated to. The resident was found on the ground and transferred to the hospital for evaluation. The resident was transferred to skilled nursing where the resident later passed away.

LPAs requested the following: 602 of resident, resident’s individual personalized plan, copy of Unusual Incident Report relating to resident’s fall, and facility communications regarding resident after the fall.

Additional staff will be interviewed.

This report was reviewed with HSD Craig Cady and an electronic copy was provided on 10/01/20 to obtain a signature
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020
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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