<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607698
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:17:39 AM

Document Has Been Signed on 07/21/2022 11:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SUNSHINE VILLAFACILITY NUMBER:
197607698
ADMINISTRATOR:FLORMINE RESURRECCIONFACILITY TYPE:
740
ADDRESS:5417 MONTAIR AVENUETELEPHONE:
(562) 895-0772
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 4DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria Tavarez; Assistant-AdministratorTIME COMPLETED:
11:33 AM
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
Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Assistant Administrator Maria Tavarez and explained the reason for the visit. Administrator Flormine Resurreccion was informed of the visit via phone call. Physical Plant was toured, medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Ms. Tavarez toured the home and observed: (4) bedrooms, (2) bathrooms,(1) staff room, living room, kitchen, dining room, and detached garage/laundry room. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 in the hallway and measured at 110.6F which is within the required 105F - 120F degrees. Grab bars and non-skid mats were observed in the bathrooms. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors and carbon monoxide detectors are intertwined and were observed throughout the facility and were tested and operable during the visit. There is a fire extinguisher located near the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and disinfectants are locked under the sink and are inaccessible to the residents. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff were observed wearing masks and screening visitors at entry.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (4) out of the (4) resident medications were reviewed. Medications are centrally stored in a cabinet in the kitchen. Furosemide 20MG dated 07/09/22 was initialed as given to R1, however medication was still in the bubble pack. Meloxicam 7.5MG dated 07/11/22 was initialed as given to R2, however medication was still in the bubble pack.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/21/2022 11:17 AM - It Cannot Be Edited


Created By: David Sicairos On 07/21/2022 at 10:49 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUNSHINE VILLA

FACILITY NUMBER: 197607698

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

(4) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on medication review, LPA observed Furosemide 20MG dated 07/09/22 was still in bubble pack for R1. Meloxicam 7.5MG dated 07/11/22 for R2 was still in bubble pack. Both medications were initialed in the MARs as being given to the residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
1
2
3
4
Administrator/Licensee to notify R1 and R2's Physicians regarding the missed medications. Administrator/Licensee to conduct in service medication training with staff members who pass out medications and submit list of attending staff members to CCL by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Stefanie Coronel
LICENSING EVALUATOR NAME:David Sicairos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2