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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700781
Report Date: 08/30/2021
Date Signed: 08/30/2021 05:14:10 PM

Document Has Been Signed on 08/30/2021 05:14 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNNY PEACE 1FACILITY NUMBER:
342700781
ADMINISTRATOR:CARRASCO IV, EUFRONIOFACILITY TYPE:
740
ADDRESS:6204 FENNWOOD CT.TELEPHONE:
(619) 861-6339
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: DATE:
08/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Eufronio Carrasco TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a case management visit. LPA Valerio was met by staff and was screened for COVID-19 symptoms prior to being allowed entry. Facility Staff confirmed resident nor staff have experienced any signs or symptoms of COVID-19 in the last ten days.

During a complaint investigation (21-AS-2021051715650), LPA Valerio attempted to retrieve an inventory sheet for Resident 1 (R1). Administrator informed LPA Valerio that an inventory sheet, a required document per Title 22 regulations,  was not completed for the resident.

During today's unannounced case management visit, LPA Valerio requested to see Admission Packets for current residents. LPA Valerio observed 5 out of 6 residents did not have an LIC 621 recorded in their file.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during this visit. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was held, and a copy of the report was left with Licensee Maria Carrasco .
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2021 05:14 PM - It Cannot Be Edited


Created By: Christina Valerio On 08/30/2021 at 02:34 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNNY PEACE 1
FACILITY NUMBER: 342700781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2021
Section Cited
HSC
1569.153

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569.153. A theft and loss program shall be implemented by the residential care facilities for the elderly...(d) A written resident personal property inventory is established upon admission... Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. This requirement was not met as evidenced by:
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Licensee stated she will complete the LIC 621 for all residents and send a scanned copy to LPA Valerio by POC due date.
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Based on observations and interviews, Licensee stated the facility did not obtain an inventory sheet for R1 and currently does not have inventory sheets for 5 out 6 residents in care. This poses a potential health and safety risk to residents in care.
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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:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


LIC809 (FAS) - (06/04)
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