445202756-5-10-2021-26-AS-KHOS-C2WJ3U-20210511064206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 04/19/2021
Date Signed: 05/10/2021 09:56:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/06/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210106164322

FACILITY NAME:	SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	445202756
ADMINISTRATOR:	MCKIE, JAMES		FACILITY TYPE:	740
ADDRESS:	80 FRONT STREET		TELEPHONE:	(831) 459-8400
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	132; 132; 132	CENSUS: 92	DATE:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	03:41 PM
MET WITH:	Tami Ojwang		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not allowing resident access to a telephone.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Ryker Heberle and Marybeth Donovan conducted a Tele-Visit due to COVID-19 Pandemic restrictions to deliver the complaint investigation finding. LPAs met with Tami Ojwang, General Manager.

Department opened a complaint on 01/08/2021 via tele-visit due to COVID-19 pandemic regarding the above allegation. During the course of the investigation, LPAs visited the facility 4 times (2/8/2021, 2/11/2021, 2/19/2021, 3/19/2021) interviewed 18 residents and 16 staff, and reviewed 9 residents' records.

Continued in 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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 2

Control Number 26-AS-20210106164322

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 445202756
	VISIT DATE: 04/19/2021

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
26
27
28
29
30
31
32

During televisit conducted on 1/8/2021, LPAs asked 3 staff members what the company policy was regarding telephone access. 3 out of 3 staff stated that all residents are allowed access to a common phone located in a private corner of the first floor hallway. Residents are also allowed to have phones in their rooms. LPAs were shown public phone and were provided the resident phone directory for residents with their own phone numbers.

Between the dates 2/8/2021 to 3/19/2021, LPAs interviewed 16 residents regarding phone use. 11 out of 16 residents interviewed stated that they had no trouble making calls when they wished to. 5 out of 16 were unable to answer the question.

Facility does not keep a log of personal calls made by residents dialed or received.

R1 expired before he/she was able to be interviewed. Document review of resident file indicates that resident would sometimes become withdrawn and refuse contact with both staff and family members. Resident's physician's report indicated bouts of paranoia and depression. R1 had his/her own phone and could be contacted directly by those who had his/her phone number.

The Department has investigated the above allegation. Based on interviews, observation, and document review, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

Report reviewed with Tami Ojwang, General Manager, and a copy of this report provided electronically for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2