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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609684
Report Date:
08/07/2024
Date Signed:
08/08/2024 10:44:42 AM
Document Has Been Signed on
08/08/2024 10:44 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
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
ADMINISTRATOR/
DIRECTOR:
SAVELLA, JEFFREY
FACILITY TYPE:
740
ADDRESS:
8001 SUNNYBRAE AVE
TELEPHONE:
(323) 455-7821
CITY:
WINNETKA
STATE:
CA
ZIP CODE:
91306
CAPACITY:
6
CENSUS:
6
DATE:
08/07/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:34 AM
MET WITH:
Jeffrey Savella- Licensee
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff Josephine Espiritu was explained the reason for the visit. At 1:00 PM Jeffrey Savella who is the licensee arrived and met with LPA, was explained the reason for the visit.
At 11:37 AM, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 1/2/2024. During the visit the facility is at 74 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; one (1) bedridden; hospice waiver for six (6).
Kitchen:
The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet under the sink of the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away under the kitchen sink.
Bedrooms:
There were six (6) bedrooms designated for residents' and staff use. Room #2, room #3, room #5 and bedroom #6 are all private. Bedroom #4 is shared. Room #1 is for staff used. Residents bedroom are properly furnished with appropriate dresser, beddings, and linens with sufficient lighting.
Continue to LIC 809-C
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
3
of
39
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
VISIT DATE:
08/07/2024
NARRATIVE
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Bathrooms:
There are four (4) bathroom designated for residents' and staff use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.1 degrees Fahrenheit for bathroom #1 located in the hallway in between room #2 and room #3. Bathroom #2 is inside bedroom #4. Hot water temperature was measured at 105.8 degrees Fahrenheit. Bathroom #3 is located beside the laundry area that is only use for staff. Bathroom #4 is beside bedroom #5 is under renovation, it is lock, closed and non-operational. There was enough clean linen available in the cabinets in the hallway.
Common Areas:
LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.
Infection control
: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.
Surrounding Grounds
: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage detached.
Laundry service:
There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet under the kitchen sink.
Staff Files
: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the kitchen. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. S3 missing TB test and health screening. Deficiency will be cited on LIC 809-D.
Continue to LIC 809-C
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
23
of
39
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
VISIT DATE:
08/07/2024
NARRATIVE
1
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Medications
are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has NOT been logged in the medications log with proper documentation from the clients’ doctor. Staff last log medication was back on 8.5.2024 for all residents. Deficiency will be cited on LIC 809-D. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.
Resident records
were reviewed for requirements and legibility: LPA reviewed client’s files for current appraisal R1, R2, R3, R4 and R6, no appraisal was seen R1, R2, R3, R4 and R6, LIC 601, no functional capability R1, R2, R3, R4 and R6; no admission agreement for R5. Deficiency will be cited on LIC 809-D. Planned activities are offered.
Facility is within CA code of Regulations Title 22 or Health and Safety Code. Deficiencies were found and cited on LIC 809-D, exit interview conducted, copy of report has been issued and discussed.
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
24
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 MAR log was not filled-in, log stop at 8.5.2024 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Staff needs to be re-trained for medication dispensing and log.
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 MAR, incomplete log of MAR, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Staff needs to be re-trained for medication dispensing and log.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
25
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents functional capability is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Licensee needs to fill-in residents functional capability.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents appraisal is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Licensee needs to fill-in residents appraisal.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
26
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents pre-admission appraisal is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Licensee needs to fill-in pre-admission appraisal when takin in a new resident.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents functional capability is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Licensee needs to fill-in functional capability when admitting a new resident.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
27
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(C)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (C) Section 87461, Mental Condition;
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents mental condition is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Licensee needs to fill-in appraisal needs and service plan.
Type B
Section Cited
CCR
87506(b)(17)(D)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (D) Section 87462, Social Factors;
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents social factor is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Licensee needs to fill-in appraisal needs and service plan.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
28
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents is missing pre-admission which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement needs to be filled-in when taking in a new resident.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents needs and service plan is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Needs and service plan is needed when taking in new resident.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
29
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents appraisal is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Appraisal needs to be filled in.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents appraisal is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Appraisal needs to be filled in
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
30
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement needs to be filled-in when takin in new resident.
Type B
Section Cited
HSC
1569.885(c)
Admission Agreements
(c) The admission agreement shall inform a resident of the right to contact the State Department of Social Services, the long-term care ombudsman, or both, regarding grievances against the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents functional capability is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement is needed when admitting a new rsident.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
31
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(l)
Admission Agreements
(l) The licensee shall attach a copy of applicable resident's rights specified by law or regulation to all admission agreements, and shall include information on the reporting of suspected or known elder and dependent abuse, as set forth in Health and Safety Code Section 1569.889.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement is needed when admitting a new resident.
Type B
Section Cited
HSC
1569.885(a)
Admission Agreements
(a) When referring to a resident’s obligation to observe facility rules, the admission agreement shall indicate that the rules must be reasonable, and that there is a facility procedure for suggesting changes in the rules. A facility rule shall not violate any right set forth in this article or in other applicable laws and regulations.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement is needed when admitting a new resident.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
32
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.886(d)
Admission Agreements
(d) The admission agreement shall state the responsibilities of the licensee and the rights of the resident when a facility evicts residents pursuant to Section 1569.682.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement is needed when takin in a new rsident.
Type B
Section Cited
CCR
87464(c)
Basic Services
(c) The admission agreement shall specify which of the basic services are desired and/or needed by, and will be provided for, each resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement is needed when takin in a new rsident.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
33
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87464(d)
Basic Services
(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission appraisal agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement is needed when admitting a new resident.
Type B
Section Cited
CCR
87507(a)(1)(A)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (A) Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement is needed when admitting a new resident.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
34
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(a)(1)(B)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (B) Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission appraisal agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Admission agreement is needed when admitting a new resident.
Type B
Section Cited
CCR
87507(b)
Admission Agreements
(b) The licensee shall complete and maintain in the resident's file a Telecommunications Device Notification form (LIC 9158, 11/04) for each resident whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled in accordance with Public Utilities Code sections 2881(a) and (c).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents admission appraisal agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
All residents needs LIC 9158.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
35
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission appraisal agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Resident was admitted on April of 2024 and no admission agreement was filled. Licensee will submit proper agreement.
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission appraisal agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Resident was admitted on April of 2024 and no admission agreement was filled. Licensee will submit proper agreement.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
36
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(g)
Admission Agreements
(g) Admission agreements shall specify the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission appraisal agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Resident was admitted on April of 2024 and no admission agreement was filled. Licensee will submit proper agreement.
Type B
Section Cited
CCR
87507(g)(3)(A)1
Admission Agreements
1. A comprehensive description of any items and services provided under a single fee, such as monthly fee for room, board and other items and services shall be listed.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents admission appraisal agreement is missing which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
Resident was admitted on April of 2024 and no admission agreement was filled. Licensee will submit proper agreement.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
37
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:31 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87508(a)(3)
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (3) Information on the resident's responsible person as specified in Section 87506(b)(6).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 6 residents identity and emergency information and emergency is missing which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
LIC 601 needs to be filled-in
Type B
Section Cited
CCR
87608(a)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 6 residents appraisal. emergency is missing which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
LIC 625 (appraisal needs and service plan) needs to be filled-in.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
38
of
39
Document Has Been Signed on
08/08/2024 10:45 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
08/07/2024
at
02:35 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:
SUNNYBRAE HOME
FACILITY NUMBER:
197609684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)(11)
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Personnel Records/Staff Training - Personnel Records Section 87412(a)(11) - Domain Focused
(11) A health screening as specified in Section 87411, Personnel Requirements - General.
POC Due Date:
08/21/2024
Plan of Correction
1
2
3
4
S3 needs health screening and TB test.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
08/07/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/07/2024
LIC809
(FAS) - (06/04)
Page:
39
of
39