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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700532
Report Date: 11/16/2021
Date Signed: 11/17/2021 12:28:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210917165455
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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary AmoahTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident has bruises on both forearms, left calf and thigh, and right neck area.
INVESTIGATION FINDINGS:
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LPA Johnson arrived unannouced to deliver findings for the above complaint allegation.

Based on the investigation by the Department it was determined that the Administrator and Caregivers denied hitting R1, R1 will have a behavior and hit her bed and walls with her body which causes bruises.

Sunshine residents stated that R1 will attack staff and residents, they stated R1 attacked resident R2 and bit the Administrator. R2 said R1 will use her arms and hands to hit and scratch people, R2 also stated that R1 one time hit R3 causing a bruise on R3.

Continued
Unsubstantiated
Estimated Days of Completion: 0
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20210917165455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 502700532
VISIT DATE: 11/16/2021
NARRATIVE
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R1's special ed teacher notice bruises on R1 starting in August 2021. She states R1 has self injurious behaviors and she will attack school staff and other students. R1's teacher's aid said R1 always hits and kicks object such as walls doors or anything. She said R1 will hit these objects when she’s frustrated, angry and having a behavior. The IPP (individual program plan) dated 8/2020 states R1 displays aggression, frustration, self injurious behavior‘s, property destruction and emotional outburst. There was several facility notes stating R1 has attacked her mother, staff and residents.

This agency has investigated the above listed allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation to be UNSUBSTANTIATED.


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
LIC9099 (FAS) - (06/04)
Page: 2 of 2