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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002399
Report Date: 06/28/2023
Date Signed: 06/28/2023 01:45:54 PM


Document Has Been Signed on 06/28/2023 01:45 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SUNSHINE ON OAKDALEFACILITY NUMBER:
455002399
ADMINISTRATOR:DARA BARZINFACILITY TYPE:
740
ADDRESS:1330 OAKDALETELEPHONE:
(530) 222-3383
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 4DATE:
06/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Donna DavisTIME COMPLETED:
02:00 PM
NARRATIVE
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On 06/28/2023, Licensing Program Analyst (LPA) Ivan Avila and Licensing Program Manager (LPM) Lauren Crocker arrived at the facility unannounced to conduct a case management inspection related to a recent incident report the Department received. LPA and LPM met with Administrator, Donna Davis, and explained purpose of inspection.

LPA, LPM and Donna Davis discussed the incident report (SIR) submitted for an incident occurring on 5/22/2023 regarding R1’s fall. LPA and LPM discussed the importance of contacting emergency medical services in events that may jeopardize the health and safety of residents in care.

A type A deficiency was cited at todays visit.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/28/2023 01:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SUNSHINE ON OAKDALE
FACILITY NUMBER: 455002399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2023
Section Cited
CCR
87465(a)(1)&(2)

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The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The licensee shall provide assistance in meeting necessary medical and dental needs.
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Licensee has updated the facility policies and procedures to call 9-1-1 for any unwitnessed falls. An inservice training will be provided to all staff regarding the updated policies and procedures, a copy of the updated policies and procedures and associated training for all staff will be submitted by 7/17/23.
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 The facility staff failed to seek timely medical attention after an unwitnessed fall wich resulted in a fracture.
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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.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2