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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 04/24/2026
Date Signed: 04/24/2026 01:38:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2026 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20260420133442
FACILITY NAME:SUNSHINE VILLA ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
445202756
ADMINISTRATOR:BOLIN, CANDACEFACILITY TYPE:
740
ADDRESS:80 FRONT STREETTELEPHONE:
(831) 459-8400
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:132CENSUS: 108DATE:
04/24/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:General Manager (GM) Candace BolinTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff mishandled resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit. LPA met with General Manager (GM) Candace Bolin. LPA stated the purpose of the visit.

On 4/20/2026 the Department received a complaint with the above allegation.

It has been alleged the the staff mishandled a resident's medication, resulting in a resident, referred to as R1, being administered another resident's medication on 4/14/2026.

On 4/24/2026 the Department conducted the intial complaint investigation visit, and interviewed General Manager (GM) Candace Bolin, and 2 Staff (S1 to S2). GM states she is aware of the medication error that occurred on 4/14/2026 with Resident R1.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 26-AS-20260420133442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
VISIT DATE: 04/24/2026
NARRATIVE
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GM states R1's was given another resident's medication in error by S1 on 4/14/2026. GM states all responsible parties were notified of the incident on 4/14/2026. GM states R1 was monitored for possible side effects. GM states R1 did not have any side effects during this incident.

On 4/24/2026 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 staff state he/she is aware of the medication error that occurred on 4/14/2026 where S1 gave R1 another resident's medication. S1 states he/she assessed R1 on 4/15/2026, taking R1's vitals, which were 'normal.' S1 states he/she also called R1's family regarding the incident.

On 4/20/2026 the Department received an incident report of the medication error for R1. The incident report states "Medication error noted: resident administered 2 medications in error. contacted after hours MD emergency line...advised to observe resident...POA and HSD notified via phone...care conference held with resident's POA on 4/16/2026."

Review of R1's physician's report dated 10/5/2023, R1 has neurocognitive impairment and cannot administered his/her own medications.

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations Title 22, are being cited on the attached LIC 9099 D. An exit interview was conducted with GM Candace Bolin and a copy of this report and appeals rights were provided.

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END OF REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20260420133442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2026
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs

This requirement was not met as evidenced by:
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 Licensee will submit a plan of action on how the facility with work to prevent medication errors, to include in-service medication traiing by POC due date of 4/25/2026.
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Based on observation, record review and interviews,on 4/14/2026 Staff S1 gave another resident's medications to R1 which poses an immediate health, safety and personal rights risk to persons 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.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
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