079200335-6-12-2024-15-AS-TSGN-D66V7V-20240612161146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200335
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:12:06 PM

Document Has Been Signed on 06/12/2024 04:12 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CALIFORNIA SUNSHINE RCFE		FACILITY NUMBER:	079200335
ADMINISTRATOR:	CRYSTAL E VAKA		FACILITY TYPE:	740
ADDRESS:	5837 MITCHELL CANYON CT.		TELEPHONE:	(925) 693-0317
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	6	CENSUS: 3	DATE:	06/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Maupuku Ofahengaue, Caregiver		TIME COMPLETED:	04:20 PM

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	On 06/12/2024 at 11:10AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct an Annual 1-Year required inspection. LPA met with Maupuku Ofahengaue, Caregiver and explained the purpose of the visit. Maupuku, caregiver contacted the administrator via telephone and explained my purpose of visit. Crystal Vaka, Administrator, arrived at 11:54AM. Administrator currently holds a certificate #6051305740 Expires 04/03/2025. The facility’s fire clearance was approved for six (6) Non ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and four (4) bathrooms. LPA did observe an enclosed swimming pool in the backyard. A comfortable temperature is maintained at 78 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 103.9 degrees Fahrenheit. Residents' bathrooms are equipped with grab bars and nonskid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/24/2023. Emergency Disaster Plan was last posted on 09/01/2023. First aid kit was observed to be complete. Fire drill last conducted on 09/01/2023. Continued LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE	FACILITY NUMBER: 079200335
	VISIT DATE: 06/12/2024

NARRATIVE

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Continue from LIC809

LPA reviewed all three (3) residents records and three (3) staff records were reviewed. LPA also reviewed a sample of medication

LPA requested the following documents to be submitted to CCLD by 06/19/2024.

· LIC 200 Application for a Community Care Facility .....
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (last page)
· Liability Insurance
· Updated Facility Sketch

LPA observed the following deficiencies:

At 11:46AM LPA observed unlocked medicine in cabinet located in the kitchen area
At 12:00PM LPA observed a swimming pool in the back yard with unsecured lock around the gate
At 12:10PM LPA observed an unlocked cabinet the common bathroom with windex and pine sol and fabuloso antibacterial multi purpose cleaner on counter near sink
At 12:28PM LPA observed resident in room #2 in a medical bed with a Half (1/2) bed rail

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy the appeal rights, and the report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/12/2024 04:12 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE	FACILITY NUMBER: 079200335
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having cleaning solutions such as windex and pine sol in an unlocked cabinet in common bathroom and fabuloso antibacterial multi purpose cleaner on counter near sink which poses an immediate health, in a safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2024
	Plan of Correction
1 2 3 4	Administrator removed the cleaning solutions and placed in a locked cabinet during visit. Deficiency cleared

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: 2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having medications in an unlocked cabinet located in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2024
	Plan of Correction
1 2 3 4	Staff immediately locked cabinet with medication during visit. Deficiency cleared.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/12/2024 04:12 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA SUNSHINE RCFE	FACILITY NUMBER: 079200335
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(e)

Personal Accommodations and Services

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having an unsecured lock around the fence of the pool which poses a potential health, safety risk to persons in care.
	POC Due Date: 06/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to purchase a secure lock and provide photos to CCLD by POC date.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a medical bed in Resident's room#2 that extends from the head half the length of the bed without a medical order or order summary which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provide an email of the order summary and or Physician orders for medical bed for resident in room#2 to CLLD by POC 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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