565801931-5-19-2023-29-AS-KLOZ-CRZ22D-20230519170034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801931
Report Date: 05/19/2023
Date Signed: 05/19/2023 05:00:40 PM

Document Has Been Signed on 05/19/2023 05:00 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 2		FACILITY NUMBER:	565801931
ADMINISTRATOR:	SAM MARON		FACILITY TYPE:	740
ADDRESS:	1482 NORMAN AVENUE		TELEPHONE:	(805) 304-5960
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	05/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Cilva Toume		TIME COMPLETED:	05:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year Inspection at the facility today. When the LPA arrived there were two staff and five residents present. Licensee Representative Cilva Toume was contacted at 2:35 PM and advised of the visit. Ms. Toume arrived shortly after the inspection began.

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. The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and in the garage. Knives were secured in a locked box. During the inspection, the LPA observed dishwasher cleaning pods in an unlocked cabinet underneath the kitchen sink. The LPA also observed cleaning supplies and disinfectants in an unlocked garage and Ajax cleaner in a cabinet with a lock that was not working properly in the restroom near bedroom 6 and bedroom 7. COMMON SPACES: In the common areas, furniture, walls, and flooring were clean and in good condition at the time of the inspection. All indoor and outdoor passages were free of obstruction. The fire extinguisher was fully charged and last purchased on 12/05/2022. At 3:07 PM, the carbon monoxide detector and smoke detectors in the common areas and bedrooms were tested and were operational. Medications are centrally stored in a locked closet in the hallway. Medications were reviewed and were observed to be be administered as prescribed and recorded on the centrally stored medication records. The backyard has covered outdoor seating for resident use. BEDROOMS: There are seven resident bedrooms and one staff bedroom. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Due to time constraints, the LPA needs to return at a later date to continue the inspection. Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiencies was observed and cited during the visit. See LIC 809-D. Exit Interview conducted and the report was reviewed with the Silva Toume. Appeal Rights and a copy of this report has been issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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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Document Has Been Signed on 05/19/2023 05:00 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 2	FACILITY NUMBER: 565801931
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 cleaning supplies and disinfectants were accessible to residents in the unlocked garage, unlocked cabinet in the kitchen, and unlocked cabinet in the restroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	The Licensee secured the items and locked the garage. Licensee understands items that can pose a danger should be inaccessible to residents at all times. Licensee will submit proof of locked cabinets in the garage by 05/23/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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