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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 11/09/2024
Date Signed: 11/09/2024 02:54:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Pang Lee
COMPLAINT CONTROL NUMBER: 26-AS-20220118113048
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: 107DATE:
11/09/2024
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Jennifer GleitsmannTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is not following COVID protocols.
Staff are not answering residents call buttons timely.
Residents are not getting medications timely.
INVESTIGATION FINDINGS:
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On 11/09/2024 at 1:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Community Relation Assistant Jennifer Gleitsmann and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 107. A brief interview with conducted with 107.

Allegation were made that the facility is not following COVID-19 protocols. The investigation included a review of records and interviews with residents and staff. The facility’s Mitigation Plan, dated January 14, 2021, was reviewed and is within CDC guidelines. LPA Lee interviewed all 7 residents, none of whom expressed concerns about the facility's adherence to COVID-19 protocols. Residents confirmed that those who test positive are required to quarantine in their rooms. Additionally, LPA Lee interviewed all 3 facility staff members, who stated that the facility follows CDC guidelines and denied the allegations.
Continuded LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 26-AS-20220118113048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/09/2024
NARRATIVE
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Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that the facility is not following COVID-19 protocols.

Allegation were made that staff are not answering residents' call buttons in a timely manner. The investigation included a review of records and interviews with residents and staff. The records indicated that response times vary by situation, averaging between 22 seconds and 57 minutes after the call buttons are pressed. LPA Lee interviewed 6 out of 7 residents, none of whom expressed concerns about the timeliness of staff responses. Residents noted that staff make good efforts to answer calls promptly. Additionally, it was learned that care staff sometimes forget to clear the resident’s call pendant while attending to other needs. LPA Lee interviewed all 3 facility staff members, who denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that staff are not answering resident’s call buttons in a timely manner.

Allegation were made that residents are not receiving their medications in a timely manner. The investigation included a review of records and interviews with residents and staff. LPA Lee reviewed the facility's eMAR Summary for August 2024, September 2024, and October 2024, which was complete. Additionally, LPA reviewed medications of 7 residents along with their corresponding eMARs and found no discrepancies. LPA Lee interviewed all 7 residents, none of whom expressed concerns about receiving their medications late. Furthermore, all 3 facility staff members denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that residents are not receiving their medications in a timely manner.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Pang Lee
COMPLAINT CONTROL NUMBER: 26-AS-20220118113048

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: 107DATE:
11/09/2024
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Jennifer GleitsmannTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Residents are not getting showers timely.
INVESTIGATION FINDINGS:
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On 11/09/2024, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Community Relation Assistant Jennifer Gleitsmann and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 107. A brief interview with conducted with 107.

Allegation were made that residents are not receiving showers in a timely manner. The investigation included a review of records and interviews with residents and staff. LPA Lee reviewed the Task Logs for three residents covering August, September, and October 2024 shower logs. Out of the three logs, only two was completed. The Task Log for Resident 1 (R1) was reviewed, and discrepancies were noted regarding the shower schedule.

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20220118113048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/09/2024
NARRATIVE
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 According to R1’s care plan, R1 is scheduled to receive one shower per week, every Wednesday. However, the records showed that R1 received:

• August 2024: 2 showers
• September 2024: 2 showers
• October 2024: 1 shower

This is below the required four showers per month as outlined in R1’s care plan. LPA Lee interviewed 6 out of 7 residents, all of whom stated they are receiving showers on time. Administrator Candi Bolin clarified that if no staff initials are recorded on a task log, it indicates that the assigned caregiver did not
initials and it is unclear if R1 received showers; however, the Task logs indicated that R1 only received 1 to 2 shower for the month of August to October 2024.

As a result, it was determined the facility was not meeting residents' hygiene needs. However, no additional notes were found to explain the lack of staff initials for R1’s showers; therefore, LPA Lee was able to corroborate the allegation that resident are not receiving showers in a timely manner.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20220118113048
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2024
Section Cited
CCR
87464(f)(1)
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Basic Services 87464(f)(1): Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidence by:

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Licensee agrees to conduct staff training on basic services by plan of correction (POC) date 11/16/2024. Licensee agrees to email training documents and staff sign in sheets to LPA Lee on POC date 11/16/2024 end of day 5:00 PM.
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Based on interviews, and file review, the licensee did not ensure R1 was received showers. This posed a potential health and safety risk to R1.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5