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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608474
Report Date: 10/14/2021
Date Signed: 10/19/2021 09:36:25 AM

Document Has Been Signed on 10/19/2021 09:36 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUN CARE HOMESFACILITY NUMBER:
197608474
ADMINISTRATOR:STEPHANIE FLORESFACILITY TYPE:
740
ADDRESS:18725 SHOENBORN STREETTELEPHONE:
(818) 384-7456
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 6DATE:
10/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Emma ParicaTIME COMPLETED:
03:30 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
Licensing Program Analyst (LPA) Angelica Arambulo conducted a case management visit regards to CM that was not completed on 9-22-21. The main administrator Stephanie Flores was contacted during the visit.

The following items were observed at that time.

The register of residents had not been updated since 2019. LPA requested a copy of the register and the staff schedule but she did not have anything on file. NO LIC500 was completed. They submitted to LPA by fax a list of their schedule. The mitigation plan that was approved was requested but no copy on file.

The above items have not been taken care of and new staff have been associated.

LPA cited for the items that were seen on last visit 9-22-21 and they were not repeated during this visit.
Medication cabinet open and unlocked, Medications on the counter in a plastic container. Sharp knives or scissor drawer unlocked and open.

Resident or staff food on the counter, in the oven or sitting unwrapped in microwave.

The resident has retained a resident who is on hospice and they do not have a hospice waiver request on file for this resident. This was expressed to the administrator on 9-22-21. According to administrator they have a consultant but there is no hospice waiver submitted. Resident #1 has been under hospice care off and on since 2019.

Citations issued, appeal rights given, exit interview conducted. Email to be sent to administrator.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Angelica Arambulo
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 3
Document Has Been Signed on 10/19/2021 09:36 AM - It Cannot Be Edited


Created By: Angelica Arambulo On 10/14/2021 at 03:10 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUN CARE HOMES
FACILITY NUMBER: 197608474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2021
Section Cited
CCR
80024

1
2
3
4
5
6
7
80024 Waivers and exceptions.
Unless prior written licensing agency approval is received as specified in (b) below, all licensees shall maintain continuous compliance with the licensing regulations. This requirement is not met as evidence of facility file review.
1
2
3
4
5
6
7
Administrator will submit a request for a hospice waiver by the due date of the POC.
8
9
10
11
12
13
14
Facility failed to obtain necessary waiver for hospice care for resident #1 who has been off and on hospice since 2019.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Eva Miller
LICENSING EVALUATOR NAME:Angelica Arambulo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/19/2021 09:36 AM - It Cannot Be Edited


Created By: Angelica Arambulo On 10/14/2021 at 03:55 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUN CARE HOMES
FACILITY NUMBER: 197608474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2021
Section Cited
CCR
87705(f)

1
2
3
4
5
6
7
Dementia 87705 (f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The administrator had made sure that this would not be repeated. During todays inspection the cabinet was locked up and no medications were on the counter or in the drawer.
8
9
10
11
12
13
14
Physical plant tour conducted on 9-22-21. The medication cabinet and sharp obects cabinet was open and left unsupervised. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Eva Miller
LICENSING EVALUATOR NAME:Angelica Arambulo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3