565801682-12-5-2022-29-AS-ASMH-CLTVH8-20221205152645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801682
Report Date: 12/05/2022
Date Signed: 12/05/2022 03:27:56 PM

Document Has Been Signed on 12/05/2022 03:27 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SUNSHINE HEALTH PLACE		FACILITY NUMBER:	565801682
ADMINISTRATOR:	SLIM MARON		FACILITY TYPE:	740
ADDRESS:	1558 NORMAN AVENUE		TELEPHONE:	(805) 446-3100
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	12/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Cilva Toume		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 1:45 p.m. The LPA met with Administrator Cilva Toume and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives were locked inaccessible in the kitchen cabinets, and the chemicals are kept in the garage. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food.

BEDROOMS: Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted.

RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 2:10 p.m., water temperature measured at 124 F. Upon observation, the Administrator adjusted the water tank. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms.

COMMON SPACES: There was a hallway closet with extra linens and towels. Smoke and common monoxide detectors were operable at that time. Medications were locked and inaccessible in the kitchen cabinet. Fire extinguisher was fully charged but there was no proof of purchase or it being serviced within the past twelve (12) months. The backyard had furniture and a covered area for resident use. There was an in-ground pool but it was locked at the time of the visit. The side gate was self-latching.

While touring the facility with the Administrator, the garage was observed to be unlocked during today’s visit. The washer and dryer were in the garage, along with additional supplies. As the garage was observed to be unlocked at the time of the visit, the chemicals and cleaning supplies were accessible, and over-the-counter medication was observed in the refrigerator in the garage.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
	VISIT DATE: 12/05/2022

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INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed at the entrance into the facility. The facility’s cleaning protocol was sufficient. There was record of staff and resident vaccinations. The Administrator is up to date regarding testing, visitation and vaccine requirements. The Administrator communicated that they needed additional Personal Protection Equipment (PPE); however, they have a sufficient supply at this time. The facility continues to conduct surveillance testing of staff and residents on a regular basis. The facility's procedures as it pertains to infection control are adequate.

Observed deficiencies noted on LIC 809D. Exit interview conducted, and a copy of this report issued. Appeal rights discussed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/05/2022 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the water temperature measured between 124 degrees F, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 12/06/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Adjust the water tank within the next 24 hours 2. After adjusting the water, keep a five day temperature log and submit to CCL within the next seven days.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there were chemicals and medications accessible, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. The items were locked upon observation. Plan of Correction met.

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

LIC809 (FAS) - (06/04)

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