<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801931
Report Date: 12/05/2022
Date Signed: 12/05/2022 01:13:16 PM

Substantiated


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
12/02/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20221202113756
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:
12/05/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cilva ToumeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is operating outside of license terms and conditions
Resident is not provided comfortable accommodations at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial 10 day visit. The LPA met with Administrator Cilva Toume and explained the reason for the visit.

Today, the LPA conducted a tour of the facility at 9:37 a.m., interviewed staff at 9:45 a.m., 10:10 a.m., and 10:17 a.m., and interviewed residents at 9:47 a.m., 10:00 a.m., and between 11:30 a.m. – 11:40 a.m.

Regarding the allegation: Facility is operating outside of license terms and conditions
It was alleged that the facility was operating outside of the license terms, as it was alleged that the facility had housed seven (7) residents. Interviews and records review confirmed that the morning of 11/30/2022, there were four (4) residents that resided at the facility.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20221202113756
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 2
FACILITY NUMBER: 565801931
VISIT DATE: 12/05/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews with the Administrator confirmed that, due to emergency circumstances of another facility closing, the Administrator accepted three (3) residents the afternoon of 11/30/2022. Records review confirmed that there were seven (7) residents from 11/30/2022 – 12/02/2022. The Administrator alleged that one (1) out of seven (7) residents was supposed to move out on 11/30/2022, however, the resident in question moved out on 12/02/2022. Whereas at this time, there are currently six (6) residents residing at this facility, there is sufficient evidence to support the claim that the facility operated outside of its licensing terms and conditions from 11/30/2022 – 12/02/2022. This allegation is deemed Substantiated at this time.

Regarding the allegation: Resident is not provided comfortable accommodations at the facility


It was alleged that the facility failed to provide comfortable accommodations to the residents of this facility. During the physical plant tour, the LPA inspected the furniture and equipment used by the residents and observed it to be in operable condition. Interviews confirmed that the staff attempted to meet all specifications and accommodations of residents in the facility to the best of their ability. The Administrator confirmed that there was a former resident that requested an electric bed and whereas the Administrator thought they had the bed as specified by the resident, it did not fully meet the resident’s expectations. As a result, the resident purchased their own electric bed.

There was also a concern raised as it alleged that the facility showers cannot accommodate residents with wheelchairs. The Administrator claimed that they had not had an issue with the residents showering in the facility and said that they were able to provide shower chairs and staff could assist those that required hands-on assistance with showering. Resident interviews confirmed that there was one resident that believed the bathrooms could not accommodate their needs as it did not allow their wheelchair to go in; whereas they were able to eventually shower, it was noted that the water appeared to be hot. The LPA observed that one (1) of three (3) restrooms required a lot of maneuvering if a resident wanted to take a shower with their wheelchair. However, a resident could be assisted to the shower chair in that bathroom if need be. The LPA observed that two (2) out of three (3) bathrooms would require a resident to be moved to a shower chair, or would require assistance for their wheelchair to be maneuvered into the shower. As such, the facility would be able to meet showering needs as requested.

However during today’s visit, the LPA tested the water in the two (2) common hallway bathrooms. At 10:25 a.m., the LPA tested the water in the 1st common hallway bathroom, and the water measured at 125.7 degrees Fahrenheit. At 10:37a.m., the LPA tested the water in the 2nd common hallway bathroom and the water measured at 124.3 degrees Fahrenheit.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20221202113756
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 2
FACILITY NUMBER: 565801931
VISIT DATE: 12/05/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the information obtained in interviews and observations, the staff attempted to meet resident accommodations as required in the resident’s medical assessment, or at the request of the resident. However, the facility failed to provide comfortable accommodations for all residents, as the water temperature measured between 124.3 – 125.7 degrees Fahrenheit. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Civil penalty assessed. Exit interview conducted, today's report and appeal rights were reviewed and issued. Signatures were obtained.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20221202113756
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 2
FACILITY NUMBER: 565801931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited
CCR
87204(a)
1
2
3
4
5
6
7
87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to do the following:
1. At this time, there are only six (6) residents. Review regulation 87204 and communicate how the facility will maintain voluntary compliance. Submit Statement of Understanding by 12/06/2022.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above, as the facility had seven (7) residents between 11/30/22-12/2/2022 when they are licensed for a maximum of six (6) residents, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Zero tolerance violation; civil penalty in the amount of $500 is assessed.
Type A
12/05/2022
Section Cited
CCR
87303(e)(2)
1
2
3
4
5
6
7
87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained ... attain a temperature of not less than 105 degree F and not more than 120 degree F.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above, as the water temperature measured between 124.3 – 125.7 degrees F, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
12/02/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20221202113756

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:
12/05/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cilva ToumeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not addressing the roach infestation at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial 10 day visit. The LPA met with Administrator Cilva Toume and explained the reason for the visit.

Today, the LPA conducted a tour of the facility at 9:37 a.m., interviewed staff at 9:45 a.m., 10:10 am., and 10:17 a.m., and interviewed residents at 9:47 a.m., 10:00 a.m., and between 11:30 a.m. – 11:40 a.m.

It was alleged that the facility had roaches. It was alleged that the roaches had been seen ‘at night’ in the hallway bathroom and brought to the attention of facility staff during the day. Staff confirmed that they had seen a bug come out of the faucet in the hallway bathroom and as a result, the facility purchased bug spray and sprayed throughout the facility.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20221202113756
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 2
FACILITY NUMBER: 565801931
VISIT DATE: 12/05/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff said they took claims of observing roaches or any pests seriously. Residents denied claims that they had seen any roaches or pests throughout the day. The LPA inspected the facility thoroughly, including the three (3) facility bathrooms, and did not observe any roaches or pests at the time of the visit.

Based on the information obtained from interviews, there is insufficient evidence to support the claim that the staff are not addressing the roach infestation at the facility. At the mention of bugs being observed, the staff purchased bug spray and acted accordingly. Staff denied claims of seeing any roaches in the facility throughout the day and said that there wasn’t an apparent infestation. Based on the information obtained, this allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 6 of 6