445202756-5-14-2026-26-AS-MTAN-DU3TX6-20260514150636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202756
Report Date: 05/14/2026
Date Signed: 05/14/2026 03:06:47 PM

Document Has Been Signed on 05/14/2026 03:06 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/ DIRECTOR:	BOLIN, CANDACE		FACILITY TYPE:	740
ADDRESS:	80 FRONT STREET		TELEPHONE:	(831) 459-8400
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY: 132		CENSUS: 108	DATE:	05/14/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	General Manager (GM) Candace Bolin		TIME VISIT/ INSPECTION COMPLETED:	03:15 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) Marcella Tarin conducted an unannounced case management incident visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit. On 1/15/2026 the Department conducted a complaint investigation visit for an unrelated complaint. During interviews, it was alleged that a staff, referred to as S1, had inappropriately used a mirror while assisting a resident, referred to as R1, during toilet assistance, on an unknown date in 2025. On 1/15/2026, the Department interviewed 10 Residents (R1 to R10). 9 Out of 10 Residents stated he/she does not have any issues or concerns with staff. R7 declined to be interviewed. On 4/6/2026 the Department conducted an interview with Witness 1 (W1). W1 stated while helping R1 with care on an unknown date in 2025, R1 told him/her that S1 was helping with toileting, when R1 used a mirror to check R1’s private area. W1 states R1 stated he/she was ‘irritated’ due to S1 ‘giggling’ during the incident. W1 does not remember the date of the incident. W1 stated R1 did not provide additional information regarding this incident. W1 stated this incident was reported to facility management. On 4/17/2026 the Department interviewed Witness 2 (W2). W2 stated he/she spoke with R1 regarding the incident with S1. W2 stated R1 told S1 that he/she was having pain when using the bathroom. W2 stated S1 used a mirror to check R1’s private area. W2 stated he/she believed it was reasonable for R1 to use a mirror at that time. Page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

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: 05/14/2026

NARRATIVE

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W2 stated he/she reported this incident to facility management and did not know additional information regarding this incident. W2 stated he/she also spoke with R1 about the incident, but R1 did not provide additional information about this incident.

On 4/28/2026 the Department interviewed Witness (W3). W3 states he/she was informed of the incident by W2. W3 states there was no documentation for an internal investigation into this incident. W3 stated he/she did not have any additional information regarding this incident.

Review of R1’s Physician’s Report dated 1/22/2025, R1 is incontinent of bowel and bladder, unable to care for his/her toileting needs. R1 has major neurocognitive disorder.

Review of S1’s file, there are no incidents noted regarding S1 being involved in abuse of residents in care. R1’s training record was reviewed, training records are dated 11/29/2023 to 1/1/2026, to include but not limited to dementia care, bladder care, incontinence care, and perineal care.

On 5/14/2026, the Department reviewed Physician Fax Communications dated 12/27/2024, 12/30/2024, and 12/31/2024, which note the facility informed R1’s physician about R1 having bowel issues, with R1 requesting a change to his/her medications for bowel incontinence.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit view was conducted with GM Candace Bolin and a copy of this report was provided.

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END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC809 (FAS) - (06/04)

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