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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700532
Report Date: 11/16/2021
Date Signed: 11/17/2021 12:29:27 PM

Document Has Been Signed on 11/17/2021 12:29 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNSHINE RESIDENTIAL IIFACILITY NUMBER:
502700532
ADMINISTRATOR:AMOAH, MARYFACILITY TYPE:
735
ADDRESS:123 PEACH BLOSSOM LNTELEPHONE:
(510) 935-8503
CITY:PATTERSONSTATE: CAZIP CODE:
95363
CAPACITY: 6CENSUS: 5DATE:
11/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Mary AmoahTIME COMPLETED:
02:30 PM
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Licensing Program Analyst Albert Johnson met with Mary Amoah to deliver finding for a complaint dated on 9/17/2021.

The Department was made aware of the incidents that were submitted to Valley Mountain Regional Center for aggressive acts on 7/27/2021, 8/25/2021 and 11/1/2021, however, Licensing did not receive these incident reports.

Per California Code of Regulations, Title 22 Division 6, Chapter 8,

Deficiencies were observed during this visit.

Exit interview held and a report given at the conclusion of the visit
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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Document Has Been Signed on 11/17/2021 12:29 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/16/2021 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNSHINE RESIDENTIAL II
FACILITY NUMBER: 502700532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2021
Section Cited
CCR
80061(b)(1)

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Reporting requirements. (b) Upon the occurrence...of any of the events specified in (1)...a report shall be made to the licensing agency within the agency's next working day...a written report containing the information...shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Licensee will conduct staff training on regulation 80061 and submit proof of completed training to LPA by POC due date
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(1) Events reported shall include...(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by: Based on record review and interviews, Licensee did not furnish incident reports to CCL for R1's aggressive acts on 7/27/2021, 8/25/2021 and 11/1/2021. This is a potential health and safety risk to residents in care.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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