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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200335
Report Date: 04/21/2022
Date Signed: 04/21/2022 11:58:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20201109145516
FACILITY NAME:CALIFORNIA SUNSHINE RCFEFACILITY NUMBER:
079200335
ADMINISTRATOR:CRYSTAL E VAKAFACILITY TYPE:
740
ADDRESS:5837 MITCHELL CANYON CT.TELEPHONE:
(925) 693-0317
CITY:CLAYTONSTATE: CAZIP CODE:
94517
CAPACITY:6CENSUS: 2DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Crystal Vaka, Administrator
Maupuaku Ofahengaue, Staff		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained an unexplained injury
Facility failed to seek resident medical attention for a fall
Resident has sustained several falls while in care
Facility failed to report resident's fall
Resident's room has feces on the wall
INVESTIGATION FINDINGS:
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On 04/21/22 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with staff (S2) and administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with staff (S2) and spoke with administrator on the phone who authorized S2 to act on her behalf and sign the reports.

Allegation: Resident sustained an unexplained injury
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, staff (S1) gave neutral witness (W1) 3 different versions of what happened to resident (R1) on 11/06/2020. S1 told W1 that R1 fell from his chair. The second version was that R1 fell from his walker. The 3rd version was that staff (S1 & S2) saw R1 on the floor when they entered his room. S1 told W1 that they gave R1 an ice pack and polysporin for his forehead lump. The preponderance of evidence has been met. Therefore, this allegation is substantiated.
Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
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 15-AS-20201109145516
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CALIFORNIA SUNSHINE RCFE
FACILITY NUMBER: 079200335
VISIT DATE: 04/21/2022
NARRATIVE
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Allegation: Facility failed to seek resident medical attention for fall
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, staff failed to seek resident (R1) medical attention for fall (11/07/20). Administrator stated R1 has loose urination and tended to urinate on the floor instead of his commode. R1 tripped on his walker and fell on his face due to the wet floor. R1’s black eye and lump above his left eyebrow did not show until after 2 days. Neutral witness (W1) confirmed staff did not seek medical attention for R1 when fall incident occurred. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Resident has sustained several falls while in care
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, staff (S1) confirmed with LPA that resident had several falls which he logged on the computer (9/13/20, 9/23/20, 10/18/20, 10/19/20 and 11/07/20. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Resident’s room has feces on the wall
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, staff (S1) confirmed with LPA that he cleaned R1’s alleged fecal matter smeared on R1’s wall on11/06/20 as instructed by neutral witness (W1) who visited facility unannounced on official business. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20201109145516

FACILITY NAME:CALIFORNIA SUNSHINE RCFEFACILITY NUMBER:
079200335
ADMINISTRATOR:CRYSTAL E VAKAFACILITY TYPE:
740
ADDRESS:5837 MITCHELL CANYON CT.TELEPHONE:
(925) 693-0317
CITY:CLAYTONSTATE: CAZIP CODE:
94517
CAPACITY:6CENSUS: 2DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Crystal Vaka, Administrator
Maupuaku Ofahengaue, Staff		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident's room is locked from the outside
INVESTIGATION FINDINGS:
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On 04/21/22 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with staff (S2) and administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with staff (S2) and spoke with administrator on the phone who authorized S2 to act on her behalf and sign the reports.

Allegation: Resident’s room is locked from the outside
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, staff (S1) stated the locks on resident’s (R1' s) door and the hallway were there for a former resident who would wander everywhere inside and try to get out of the facility. This former resident was sent to the hospital 8 months ago and never returned to the facility. S1 stated he forgot to remove the locks until the Ombudsman noticed them on 11/06/20 and told him to remove them which he did remove the door latch on the same day. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Exit interview conducted and a copy of this report provided via email.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20201109145516
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE
FACILITY NUMBER: 079200335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
87468.2(a)(4)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on residents’ personal rights as specified under Title 22 regulation Section 87468.2. Administrator will submit to CCLD copy of completed staff retraining.
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This requirement was not met as evidenced by resident sustaining unexplained injury which posed a potential health & safety risk to residents in care.
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Type B
05/20/2022
Section Cited
CCR
87705(b)(1)
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The plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes
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By POC due date, administrator agrees to conduct in-service staff retraining on timely addressing residents’ medical needs. Administrator agrees to submit completed staff retraining certifications to CCLD
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This requirement was not met as evidenced by staff failing to seek medical attention for resident's fall which posed a potential health & safety risk to residents in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20201109145516
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE
FACILITY NUMBER: 079200335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
87705(b)(2)
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The plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper supervision and care of residents. Administrator will submit to CCLD copy of completed staff retraining.
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This requirement was not met as evidenced by resident sustaining several falls which posed a potential health & safety risk to residents in care.
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Type B
05/20/2022
Section Cited
CCR
87211(a)(1)
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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on reporting requirements as specified under Title 22 regulation Section 87211. Administrator will submit to CCLD copy of completed staff retraining.
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This requirement was not met as evidenced by staff not reporting incidents to the licensing office which posed a potential health & safety risk to residents in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20201109145516
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE
FACILITY NUMBER: 079200335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
87468.1(a)(2)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on residents’ personal rights as specified under Title 22 regulation Section 87468.1. Administrator will submit to CCLD copy of completed staff retraining .
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This requirement was not met as evidenced by fecal smears on resident's wall which posed a potential health & safety risk to residents in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6