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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 11:55:00 AM

Unsubstantiated


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
12/07/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211207092953
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:
10:30 AM
MET WITH:Crystal Vaka, Administrator
Maupuaku Ofahengaue, Staff		TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff is not allowing resident the option of choosing their preferred hospice agency provider.
INVESTIGATION FINDINGS:
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On 04/21/22 at 10:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with staff (S2) and administrator (ADM) to deliver the finding of above allegation. LPA explained the purpose of the visit with S2 and spoke to administrator on the phone who authorized S2 to act on her behalf and sign the reports..

Allegation: Staff is not allowing resident the option of choosing their preferred hospice agency provider.
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, staff (ADM) stated each resident who is ordered by his/her doctor to be under hospice care chooses their own hospice agency provider. Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
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 2
Control Number 15-AS-20211207092953
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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Facility staff does not dictate or force any resident to use a specific hospice care agency. They do not have a specific hospice agency that they use. The issue with resident (R1) was that her authorized representative and family refused to communicate R1's hospice care plan with staff because they did not want to pay the additional $50 per day for hospice care as specified in their admission agreement.

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.

No deficiencies cited. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
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 2