502700653-4-4-2022-27-AS-SDOB-CDAPJS-20220408112202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700653
Report Date: 04/04/2022
Date Signed: 04/04/2022 03:41:51 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
11/09/2021 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20211109111019

FACILITY NAME:	SUNSHINE RESIDENTIAL III		FACILITY NUMBER:	502700653
ADMINISTRATOR:	AMOAH, MARY		FACILITY TYPE:	735
ADDRESS:	1233 FAWN LILY DRIVE		TELEPHONE:	(510) 935-8503
CITY:	PATTERSON	STATE: CA	ZIP CODE:	95363
CAPACITY:	6	CENSUS: 0	DATE:	04/04/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Mary Amoah		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained bruises while in care

Staff did not safeguard resident's personal belongings

Staff are not providing a comfortable enviornment

INVESTIGATION FINDINGS:

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LPA Jason Lund arrived at the facility unannounced to deliver findings for the above complaint allegations. LPA Lund met with Administrator Mary Amoah and explained the reason for the visit.

Based on interviews with staff, witness, and documentation from the facility. C1 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 a behaviorist to work on the above behaviors.

LPA reviewed documentation from the facility stating that C1 had incidents at school and at the facility. LPA interviewed staff and clients in care regarding the care of clients, staff and clients reported no incidents that would cause injury to clients in care. Staff stated that they would report in such incidents to Administrator Mary Amoah. The reports state that C1 repeatedly would have behaviors (incidents) and could have sustained bruises while having the behaviors while at the facility or at school.

Unsubstantiated

Estimated Days of Completion: 90

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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211109111019

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 III	FACILITY NUMBER: 502700653
	VISIT DATE: 04/04/2022

NARRATIVE

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LPA Lund interviewed staff, witnesses and observed C1’s clothing in C1’s room. LPA observed clean and suitable clothing for C1 during visit on 1/13/2022. LPA didn’t observe any ripped pants in C1’s clothing. C1 could have behaviors and could have ripped C1’s pants during a behavior. Staff notate all behaviors but do not notate if C1 or clients would damage their clothes. They would just put another piece of clothing on the clients.

LPA Lund reviewed facility documentation, interviewed staff and witnesses. C1 was the only client at the facility and would roam around the facility until C1 would finally go to bed. C1 would sleep C1’s bed, on the floor, corners of the different rooms and on the couch. C1 would also have behaviors and break facility furniture and try to get out the facility all different times of the day and night. C1 eventually received Patch from Valley Mountain Regional Center which is 1 staff to 1 client service for 10 hours through the day and 2 hours at night. On 11/29/2021 C1 had an change in C1’s medication to help C1’s to sleep better at night.

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: 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

LIC9099 (FAS) - (06/04)

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