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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318075
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:30:14 PM

Document Has Been Signed on 01/29/2024 03:30 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SUNSHINE GLORY CARE HOMEFACILITY NUMBER:
340318075
ADMINISTRATOR:AGUDA, MERLYFACILITY TYPE:
740
ADDRESS:9845 ALTA MESA ROADTELEPHONE:
(916) 687-7874
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY: 12CENSUS: 11DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Merly AgudaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Merly Aguda and explained the purpose of the visit.

Upon entry, LPA Moleski observed a drawer left open at a desk in a common area. The drawer contained empty medication packaging, as well as medications left in bubble packs. LPA Moleski observed a medication tablet on the floor beneath the desk.

LPA Moleski reviewed three resident files (R1-R3) and three staff files (S1-S3). Appraisal/needs and services plans for R1-R3 were over one year old.

LPA Moleski toured the facility with Aguda and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions.

LPA Moleski interviewed one staff member (S3) and one resident (R1).

This facility is being cited per 22 CCR Sections 87465(h)(2) and 87463(c). An exit interview was held with Aguda. Appeal rights and a copy of this report were left with Aguda.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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 01/29/2024 03:30 PM - It Cannot Be Edited


Created By: Vincent Moleski On 01/29/2024 at 03:11 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNSHINE GLORY CARE HOME
FACILITY NUMBER: 340318075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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
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Based on observation, the licensee did not ensure medications were locked and inaccessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
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Licensee agrees to destroy the medications by POC due date, and afterward to send LPA Moleski a copy of the medication destruction record.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/29/2024 03:30 PM - It Cannot Be Edited


Created By: Vincent Moleski On 01/29/2024 at 03:11 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNSHINE GLORY CARE HOME
FACILITY NUMBER: 340318075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) 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, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not ensure appraisals/needs and services plans were updated at least annually for at least three residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Licensee agrees to provide LPA Moleski updated appraisals/needs and services plans for R1-R3 by the POC due date.
vincent.moleski
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
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