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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801931
Report Date: 05/05/2021
Date Signed: 05/05/2021 09:47:22 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:
05/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cilva ToumeTIME COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena 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.

The investigation revealed that when R1 was found on the floor on 8/26/2020 at 4 a.m. and was assessed by Staff #1 (S1), Resident #1 (R1) complained of generalized leg pain. Thinking that it was the same generalized pain in R1’s right leg known to the facility, S1 put R1 back to bed without further assessment. S1 did not call 9-1-1 or immediately inform the Administrator. At 8 a.m., the Administrator came to the facility and the Administrator inquired about R1, to which S1 informed the Administrator that R1 had fallen. While changing R1, R1 mentioned to the Administrator that they were in pain. Hospice was notified, and an x-ray was ordered. The portable x-ray was completed at 11:40 a.m. on 8/26/2020 and the fracture to the left hip was discovered.

Based on the information obtained, staff failed to seek medical attention for R1 in a timely manner. When R1 communicated leg pain after being found on the floor, staff did not notify hospice or the Administrator until hours later. Thereafter, an x-ray taken at 11:40 a.m. revealed that R1 suffered a fractured left hip. After discussion with R1's family and R1's physician, 9-1-1 was called at 4:55 p.m.

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: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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 2
FACILITY NUMBER: 565801931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2021
Section Cited

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87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis....
This requirement is not met as evidenced by:
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Based on interview and record review, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, 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: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2021
LIC809 (FAS) - (06/04)
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