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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609850
Report Date: 07/24/2023
Date Signed: 07/24/2023 07:05:37 PM


Document Has Been Signed on 07/24/2023 07:05 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
WOODLAND HILLS NORTH, 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:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Mike TrejoTIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 08:15 a.m. When the LPA arrived, there was one staff and six residents present. The LPA was greeted by Caregiver Oscar Ortega and informed them of the reason for the visit. Administrator Mike Trejo shortly arrived.

At approximately around 8:20 a.m. the LPA observed one of the residents (R5) agitated, walking in different directions within the home and stating, “I don’t know why I am here.” R5 appeared to be in distress and confused. Caregiver Ortega redirected R5 to sit down several times and telling R5, “Please sit down, so you don’t trip or hurt yourself.” At 8:25 a.m. the caregiver redirected R5 to sit down in a wheelchair and was going to place a restraining belt on R5 in the wheelchair. Upon observation, the LPA intervened and told the caregiver they cannot restrain residents. The Caregiver seemed confused, and asked the LPA, if they are not allowed to use the belt. The LPA had a conversation with the caregiver about following regulations and making sure residents are being well taken care of in a safe manner. The administrator arrived shortly after, and the LPA informed them of the incident and the administrator stated the caregiver should not have done that and that they will make sure all staff is trained on safely handling residents. The LPA advised the administrator they should contact R5’s physician and family.

At 08:35am the LPA conducted a tour of the physical plant with Administrator Mike. The following was noted: Facility is a single-story residence that consists of four resident bedrooms and two bathrooms. The LPA observed (2) fire extinguishers last serviced in 2021. Upon observation, the administrator took both fire extinguishers to get serviced during the visit. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. The LPA observed all required postings throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.
Report will continue on 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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 07/24/2023 07:05 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SUNSHINE MANOR
FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

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, the licensee did not comply with the section cited above as the two fire extinghishers in the home were last serviced in 2021 which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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The administrator went out to service both fire extinghishirs during the visit and provided proof to the LPA.
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one out of six staff (S1) did not have TB documented in their health screening, or proof of negative TB which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Upon observation, staff 1 went to emergency care to get TB tested. The administrator agrees S1 will not be back at the home until negative results are provided and provide test results to CCL by 7/26/23
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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2023 07:05 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SUNSHINE MANOR
FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 following was accesible to residents with dementia: razors, medication, bleach, tools, fertilizer, and other.., which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Upon observation, the administrator stored all items inside the home in a locked closet, and agrees to due an inspection of the backyard and place all items that can consitute a danger to residents in a locked shed and/or garage and submit proof to CCL BY 7/25/23. The administrator also agrees all staff will receive training in dementia care and submit proof to CCL by 8/4/23.
Type A
Section Cited
CCR
87608(a)(1)
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.
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 LPA observed a caregiver restraining a resident in a wheel chair with a gait belt which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Staff immidiately removed the belt off of the resident upon LPA's intervention. The administrator agrees all staff will receive training on safely redirecting residents in care and submit proof of training by 8/4/23
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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2023 07:05 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SUNSHINE MANOR
FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 one of two bathrooms were observed to not have a slip mat which poses a potential health and safety risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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The administrator agrees to place a slip mat in the restroom and provide proof to CCL by 7/25/23.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as four out of four staff are misisng 3 out of 8 hours of dementia care which poses a potential health and safety risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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The administrator agrees all staff will receive the remaining three hours of dementia care training and submit proof to CCL by 8/4/23.
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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 07/24/2023 07:05 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SUNSHINE MANOR
FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as four out four staff files reviewed were missing 3 out of 4 hours of postural supports, restricted conditions or health services, and hospice care training which poses a potential health and safety risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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The administraor agrees all staff will receive the remaining training and provide prood to CCL by 8/8/23
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as out of the five files reviewed, the LPA identified that one resident (R3) is missing a physicians report, two residents (R1 & R2) need an updated physicians report, due to the diagnosis of dementia, and two residents (R1 & R2 ) need an annual Appraisal & Needs and Service Plan report, due to the diagnosis of dementia, which poses a potential health and safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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The administrator agrees he will obtain all physcisians reports needed and complete all appraissals & needs and services plans and submit proof to CCL BY 8/8/2023.
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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE MANOR
FACILITY NUMBER: 567609850
VISIT DATE: 07/24/2023
NARRATIVE
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Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. At 8:44 a.m. The LPA observed an insufficient amount of perishable and non-perishable food at the facility for six residents. Upon observation, staff stated they had scheduled to go grocery shopping today, and wanted to make sure most items were finished before doing so. Staff showed the LPA a bag of grocery items they had brought to the home. Sharp objects are stored in a locked drawer, and cleaning chemicals are stored in a locked closet room. At 9:36 a.m. the LPA observed Clorox wipes in the kitchen. Upon observation the administrator stored them inaccessible to residents in care. At 2:00 p.m. staff showed the LPA all the fruit, meat and produce they had gone out and purchased during the visit. Staff also showed the LPA additional cabinets with non-perishable items and stated they had forgotten to show them during the tour due to being nervous.

Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 8:52 a.m. the LPA observed the following personal hygiene items in room#4: perineal cleanser, shampoo & body wash. Both residents in room#4 are diagnosed with dementia. One (R1) of the two residents in room#4 is at risk if allowed direct access to personal grooming and hygiene items.

Bathrooms: LPA observed both bathrooms to be properly supplied and had functional fixtures. At 9:00 a.m. The LPA observed the outside bathroom without a slip mat and a pet shampoo on a shelf. Residents have sufficient amounts of supplies for personal hygiene. At 9:51 a.m. water measured 106.2 degrees Fahrenheit in one of the restrooms. At 9:16 a.m, the LPA observed a Ziploc bag full of disposable razors in the bathroom inside room#3. Upon observation, the administrator stored the pet shampoo and razors inaccessible to residents in care.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 76 degrees.



Garage: The garage is used as a storage and kept locked and inaccessible to residents in care.

Report will continue on 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE MANOR
FACILITY NUMBER: 567609850
VISIT DATE: 07/24/2023
NARRATIVE
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Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. The LPA observed a swimming pool properly gated, locked, and inaccessible to residents in care. The LPA observed all of the following in the back yard between 9:24 a.m. and 9:35 a.m. accessible to residents in care: three ladders, one hammer, one shovel, unlocked toolbox, fertilizer, a full container of bleach, one box of Aleve pills, and four prescription medication bottles (2 with Memantine tablets, and 2 with Simvastatin tablets). Upon observation the administrator locked all medication, and stated they will be cleaning the backyard and make sure all hazardous items to residents are locked and inaccessible to residents in care, due to five out of six residents diagnosed with Dementia.

File review: A review of facility files was initiated at 9:45 a.m. and the following was observed.
The LPA reviewed five (5) of six (6) resident Files. Out of the five files reviewed, the LPA identified that one resident (R3) is missing a physicians report, two residents (R1 & R2) need an updated annual physicians report, due to the diagnosis of dementia, two residents (R1 & R2 ) need an annual Appraisal & Needs and Service Plan report, due to the diagnosis of dementia, and one resident (R4) is missing TB information. The LPA reviewed four (4) out of five (5) staff files and the administrator’s file. Out of the four staff files reviewed, the LPA identified that four out of four staff are missing 3 hours of dementia annual training, 5 hours of annual medication training and 3 out of 4 hours of postural support and prohibited health training hours. The LPA also observed staff (S1) missing TB documents. Upon observation, S1 attempted to obtain TB documents from their physicians, and once they were unsuccessful, S1 went to emergency care to get TB tested and will not return to the home until results are given.

Interviews: During the visit the LPA conducted three (3) resident and three (3) staff interviews. No concerns voiced at this time.

Due to time constraints the LPA will return to complete the annual at a later date.

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

Exit interview conducted and copy of the report and appeal rights provided

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7