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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700653
Report Date: 06/30/2025
Date Signed: 07/01/2025 09:38:03 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2025 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20250513150707
FACILITY NAME:SUNSHINE RESIDENTIAL IIIFACILITY NUMBER:
502700653
ADMINISTRATOR:AMOAH, MARYFACILITY TYPE:
735
ADDRESS:1233 FAWN LILY DRIVETELEPHONE:
(510) 935-8503
CITY:PATTERSONSTATE: CAZIP CODE:
95363
CAPACITY:6CENSUS: 2DATE:
06/30/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Mary AmoahTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not ensure resident's medication was centrally stored and inaccesible to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to open and a complaint investigation. LPA Lund met with Administrator Mary Amoah and explained the reason for the visit.
Staff did not ensure resident's medication was centrally stored and inaccessible to residents in care - LPA Lund interviewed RP, Staff, and Administrator Mary Amoah. Administrator Mary Amoah stated to LPA Lund that it was observed that Client (C1) medication was in the butter tray area of the refrigerator and not locked in the medication lock box during a visit.
Based on interviews with RP, Staff and Administrator Mary Amoah , the information provided, it clear that staff did not ensure resident's medication was centrally stored and inaccessible to residents in care therefore the allegation was deemed SUBSTANTIATED.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
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 3
Control Number 27-AS-20250513150707
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNSHINE RESIDENTIAL III
FACILITY NUMBER: 502700653
VISIT DATE: 06/30/2025
NARRATIVE
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As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D.

An exit interview was conducted, and copies of the report and appeal rights left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250513150707
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNSHINE RESIDENTIAL III
FACILITY NUMBER: 502700653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2025
Section Cited
CCR
80075(k)(1)
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(k)The following requirements shall apply to medications which are centrally stored:(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator Mary Amoah will go over the regulatons and email LPA Lund. All medications will be locked in lock box.
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This requirement is not met evidenced by: stated to LPA Lund that it was observed that Client (C1) medication was in the butter tray area of the refrigerator. This poses an immediate 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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3