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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609850
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:42:16 PM

Document Has Been Signed on 08/24/2023 03:42 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:
08/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Mike TrejoTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 07/24/2023. The LPA was greeted by staff Bertha Trejo and informed them of the reason for the visit. Administrator Mike Trejo arrived shortly.

Today the LPA conducted a medications Audit.

Medication audit: A medication audit was initiated at 1:30 p.m. and the following was observed. The medications were stored in a kitchen cabinet, which was locked and inaccessible to the clients. During Resident #1 (R#1's) audit, the LPA observed Sertraline in R1’s medication basket, however the LPA could not verify a current Physician’s order for this medication. The LPA observed seven (7) medications missing that R1’s physician had given an order for.
During R#2's audit, the LPA observed Potassium not logged in in the Centrally stored medication and destruction record.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to administrator Mike Trejo.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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 08/24/2023 03:42 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/24/2023 at 03:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE MANOR
FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

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 in seven medicatinotons being available for R1, 1 medication without a current physicians order for R1, and 1 medication not logged for R2, which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
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 During the visit, administrator Mike contacted R1's family member and pharmacy to get all medication orders filled. Administrator Mike agrees to complete a medication audit of all residents medications to ensure accuracy, and get physicians order for R1's Sertraline. The administrator will submit proof of POC no later than 8/29/23
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:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
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