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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801931
Report Date: 04/27/2021
Date Signed: 04/27/2021 11:40:28 AM

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 2FACILITY NUMBER:
565801931
ADMINISTRATOR:SAM MARONFACILITY TYPE:
740
ADDRESS:1482 NORMAN AVENUETELEPHONE:
(805) 304-5960
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
04/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Cilva ToumeTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20200901153501.

During today’s visit, the LPA audited medications for six out of six residents. Out of six residents, medication errors were identified for three out of six residents (R1, R2, R3).

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).



Exit interview conducted, today's report and appeal rights were reviewed and issued via email. Signatures were obtained.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
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
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 2
FACILITY NUMBER: 565801931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2021
Section Cited

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87465(a)(5) Incidential Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Based on medications review and interview, the licensee did not comply with the section cited above, as the medication count was off for three out of six residents (R1, R2, R3), which poses an immediate health and safety risk to residents in care.
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2. Complete an in-service medication training for staff. Be sure to discuss logging PRN medication and reviewing prescription labels. Submit proof of completion to CCLD by 5/7/2021.

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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: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2021
LIC809 (FAS) - (06/04)
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