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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609850
Report Date: 07/24/2024
Date Signed: 07/24/2024 07:08:58 PM


Document Has Been Signed on 07/24/2024 07:08 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 MANORFACILITY NUMBER:
567609850
ADMINISTRATOR:TREJO, MIKEFACILITY TYPE:
740
ADDRESS:19 E AVENIDA DE LOS ARBOLESTELEPHONE:
(805) 241-9687
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Mike TrejoTIME COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Erica Mosley and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:52AM. LPAs were greeted by staff who contacted Licensee/Administrator Mike Trejo who arrived at the facility at approximately 10:10AM. Entrance interview conducted.

Beginning at 10:20AM, the LPAs, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Combination hardwired smoke/carbon monoxide detectors were tested at 05:44PM and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 06/28/2024.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility does have an in-ground pool which was observed to be properly fenced and locked inaccessible to residents in care. Facility has two total gates, both gates were observed to be self-latching and closing, however the side with an appropriate pathway for non-ambulatory residents was observed to have multiple items in the walkway, including an unused bed frame and propane tanks.

COMMON AREAS: This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. Fireplace was noted to be screened and inaccessible to residents.

KITCHEN: The LPAs observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable
Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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 07/24/2024 07:08 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 MANOR
FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as R1 and R2 were observed to be in Bedroom #4, which has an ambulatory only fire clearance, but R1 is non-ambulatory and R2 was observed to be non-ambulatory, but is documented as bedridden, as well as R3 is marked bedridden, but is in a non-ambulatory room which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Licensee/Administrator indicated he will switch rooms for the residents identified. Administrator understands that only residents with an ambulatory designation can be in Room #4. Administrator will also obtain clarification from both R2 and R3's physicians on whether they are bedridden or are non-ambulatory. Administrator will draft a letter to the residents' families, contact the residents' physicians for updated reports, and provide proof to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 07:08 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 MANOR
FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the toilet in the shared resident restroom was backing up and there was clutter in the outside walkway of the facility, which poses potential health and safety risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Administrator repaired the toilet during today's visit. Administrator will remove the items from the outside walkway and provide proof to CCL by POC due date.
Type B
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as R3 has medications that are prescribed as needed (PRN) however, the facility does not have a PRN authorization form and the nurse directed the staff to administer the medication daily without providing a new presciption order, which poses a potential health risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Administrator will contact R3's hospice and obtain clarification on this order. Administrator will provide proof to CCL of a change in order or a PRN authorization letter for R3 by POC due date.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 07:08 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 MANOR
FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, as 1 resident (R3) out of 6 residents observed has full bed rails, but is no longer on hospice care, which poses a potential personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Administrator indicated that R3's bed rails are adjustable and can be shortened to meet regulation. Administrator will adjust the bedrails and provide proof to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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 MANOR
FACILITY NUMBER: 567609850
VISIT DATE: 07/24/2024
NARRATIVE
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food and emergency water. The LPAs observed one designated drawer where knives and sharps are stored locked and inaccessible to residents. Medications and first aid supplies were locked in a large cabinet in the kitchen area.

LAUNDRY: The laundry room is located adjacent to the kitchen. Laundry supplies and chemicals are stored in the locked laundry room, inaccessible to residents in care. There was an additional staff restroom located in the laundry area.

BEDROOMS: There are 4 (four) bedrooms in the facility; 2 (two) are designated for shared resident use and 2 (two) are for private resident use. At 10:37AM, LPAs observed Resident #1 (R1) and Resident #2 (R2) residing in Room #4. R1 has full bed rails on their bed, but is not on hospice care at this time. LPAs observed fire clearance for Bedroom #4 is for ambulatory only. R1's physician's report indicates they are non-ambulatory and R2's physician's report indicates they are bedridden, although Administrator indicates R2 is non-ambulatory and LPAs observed R2 sitting at the kitchen table unassisted upon arrival at the facility. All 4 (four) resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

BATHROOMS: There are two (2) bathrooms for resident use, one (1) of which is a shared resident restroom located in the hallway and one (1) is a private resident restroom. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in both restrooms and was observed to be within the required range.

RECORD REVIEW: Began at 11:05AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs spoke with the Administrator regarding the facility's infection control policies and reviewed the facility's emergency disaster plan. The facility does not have a documented infection control plan, only a COVID mitigation plan. Emergency disaster plan was complete and reviewed annually. Emergency disaster drills are conducted quarterly, with the last drill documented on 03/23/2024. Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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 MANOR
FACILITY NUMBER: 567609850
VISIT DATE: 07/24/2024
NARRATIVE
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MEDICATION REVIEW: Began at 05:19PM. Medications for 2 (two) residents were observed. One (1) resident (Resident 3 – R3) had PRN (as needed) medications prescribed, however the Administrator indicated there is no document on file from R3's physician indicating how they determine their need for PRN medication. Further, R3's hospice nurse indicated R3 should take the PRN medication daily, but R3's physician did not document the change in order.

INTERVIEWS: LPAs interviewed 1 (one) staff and attempted to interview 2 (two) residents.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $500. Licensee was advised that failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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