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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801682
Report Date: 06/25/2021
Date Signed: 06/25/2021 02:21:13 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210618100158
FACILITY NAME:SUNSHINE HEALTH PLACEFACILITY NUMBER:
565801682
ADMINISTRATOR:SLIM MARONFACILITY TYPE:
740
ADDRESS:1558 NORMAN AVENUETELEPHONE:
(805) 446-3100
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Cilva ToumeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility does not provide a safe environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Ashley Smith, Salia Walker, and Martha Guzman-Chavez arrived unannounced for an initial complaint visit. The LPAs met with Cilva Toume and explained the reason for the visit. During the visit, the LPAs interviewed six residents from 9:35 a.m. – 10:45 a.m., and interviewed staff at 9:54 a.m., and 11:02 a.m., and 11:16 a.m. Also, the LPAs interviewed a family member for Resident #1 (R1) on 6/22/2021 at 5:05 pm.

Regarding the allegation, it was alleged that individuals feel unsafe in the home because R1 yells, accuses people of stealing, attempts to hit staff, and has made threats. Interviews with staff and residents corroborated the claim that R1 yells, making accusations, and individuals have observed R1 attempting to hit staff. Out of the residents and staff interviewed, three persons confirmed that they either currently or have previously felt unsafe due to R1. Based on the information obtained, there is sufficient evidence to support the claim that the facility does not provide a safe environment for residents. This allegation is deemed Substantiated at this time. Deficiencies cited on 9099-D. Exit interview conducted. A copy of the report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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 3
Control Number 29-AS-20210618100158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE HEALTH PLACE
FACILITY NUMBER: 565801682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Administrator is going to talk to each resident and staff to assess safety and to develop a plan to ensure that residents and staff are safe in the home. Communicate plan to CCLD by 6/28/2021.
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Based on interviews, the licensee did not comply with the section cited above, as it was communicated that persons felt unsafe in the facility based on R1’s behaviors, which poses an immediate 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210618100158

FACILITY NAME:SUNSHINE HEALTH PLACEFACILITY NUMBER:
565801682
ADMINISTRATOR:SLIM MARONFACILITY TYPE:
740
ADDRESS:1558 NORMAN AVENUETELEPHONE:
(805) 446-3100
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Cilva ToumeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
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5
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7
8
9
Facility staff did not address change in resident's medical condition.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Ashley Smith, Salia Walker, and Martha Guzman-Chavez arrived unannounced for an initial complaint visit. The LPAs met with Cilva Toume and explained the reason for the visit. During the visit, the LPAs interviewed six residents from 9:35 a.m. – 10:45 a.m., and interviewed staff at 9:54 a.m., and 11:02 a.m., and 11:16 a.m. Also, the LPAs interviewed a family member for Resident #1 (R1) on 6/22/2021 at 5:05 pm.

Regarding the allegation, it was alleged that R1’s behaviors have gotten worse and R1 needs to be re-evaluated. Interviews with the Administrator and the family member of R1 revealed that R1’s condition has remained stable and R1 becomes more agitated when they are not compliant with their medication regimen. R1’s family member confirmed that R1 has been evaluated on several occasions and that R1's condition remains stable. Based on the information, there is insufficient evidence to support the claim that the facility staff did not address change in resident's medical condition. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3