<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700653
Report Date: 04/04/2022
Date Signed: 04/04/2022 03:40:13 PM

Document Has Been Signed on 04/04/2022 03:40 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 IIIFACILITY NUMBER:
502700653
ADMINISTRATOR:AMOAH, MARYFACILITY TYPE:
735
ADDRESS:1233 FAWN LILY DRIVETELEPHONE:
(510) 935-8503
CITY:PATTERSONSTATE: CAZIP CODE:
95363
CAPACITY: 6CENSUS: 0DATE:
04/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Mary AmoahTIME COMPLETED:
03:45 PM
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
LPA Jason Lund arrived at the facility unannounced to do a case management visit regarding a complaint investigation. LPA Lund met with Administrator Mary Amoah and explained the reason for the visit.

LPA Lund received a complaint on 12/24/2021 regarding the facility windows are missing screens & staff are blocking doors and windows with chairs. The complaint was made at the previous facility that Client (C1) was at.

Based on LPA Lund’s observation and interviews with a witness, the facility upstairs windows were missing window screens in the client’s windows. (C1) was observed looking out the window with the window open on the 2nd floor without a window screen during a visit. LPA Lund observed a window screen at the front door on the facility and the 2nd floor window screen was missing.

Based on interviews with staff, and witness the facility placed a dresser in front of the window of C1 2nd floor room to try to prevent C1 from going out the window of C1’s room. C1’s Valley Mountain Regional Center Individual Program Plan dated 11/20/2019 states that C1 has behaviors including aggression, frustration, running way, and throwing items. C1 is working with C1’s behaviorist to work on the above behaviors.

As a result of this visit, the following deficiencies were cited on 809-D, per California Code of Regulations, Title 22.
Exit interview held and copy of report given at the conclusion of this visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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 04/04/2022 03:40 PM - It Cannot Be Edited


Created By: Jason Lund On 04/04/2022 at 03:09 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 III
FACILITY NUMBER: 502700653

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2022
Section Cited
CCR
80087(a)

1
2
3
4
5
6
7
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
1
2
3
4
5
6
7
Administrator/Licensee will put window screens on all the window that need window screens
8
9
10
11
12
13
14
This regulation was not met by evidence by: LPA Lund observed a window screen at the front door on the facility and the 2nd floor window was missing a window screen. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022


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