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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 04/24/2026
Date Signed: 04/24/2026 01:48:18 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
11/18/2025 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20251118105256
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):
1
2
3
4
5
6
7
8
9
Resident sustained injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/24/2026 Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint visit to deliver complaint findings. LPA met with General Manager (GM) Candace Bolin LPA stated the purpose of the visit.

On 11/18/2025 the Department received a complaint with the above allegation.

On 11/18/2025 the Department interviewed Reporting Party (RP). RP stated on 11/14/2025 while facility staff were repositing a resident, referred to as R1, facility staff hit R1's head on his/her headboard. RP stated facility staff informed him/her about this incident on 11/15/2025. RP stated he/she visited R1 on 11/15/2025 and saw a bandage on the top of R1’s head.

Page 1 of 2
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)
Page: 1 of 3
Control Number 26-AS-20251118105256
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
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
26
27
28
29
30
31
32
On 11/19/2025 the Department conducted a complaint investigation visit and interviewed 8 Staff (S1 to S8) and 1 Resident (R1). 8 Out of 8 staff stated he/she had heard about R1 sustaining an injury to his/her head on 11/14/2025. S7 stated he/she observed R1 ‘down the bed" on 11/14/2025 during the evening shift (2:45PM to 11:00PM). S7 stated he/she placed a bed sheet underneath R1 and then began pulling R1 up, when R1 stated “we bumped my head.” S7 stated a pillow was placed at the top of the bed before he/she moved R1 in the bed. S7 stated he/she then checked R1’s top of the head and observed a ‘red spot, less than an inch large’ and the area was not open (not an open wound). S7 stated he/she reported this incident to the MedTech on duty on 11/14/2025.

On 11/19/2025 the Department interviewed R1. R1 stated a staff ‘pulled him/her up, hit on the wall.” R1 did not provide additional information regarding this incident. R1 was observed with a bandage on the top of his/her head during the interview.

Review of R1’s physicians report dated 5/16/2023, R1 does not have a history of skin breakdown and is able to follow instructions. Review of R1’s care plan dated 3/25/2025, for transferring, R1 level of assistance is noted as ‘extensive-Resident requires frequent hands-on assistance with transfers and or changes in position. The care plan also does not require a two person assist with transfers.

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 appeal rights were provided.

Page 2 of 2

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-20251118105256
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)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This was not met as evidenced by:
1
2
3
4
5
6
7
Licensee states she will submit a plan of correction regarding how the facility will ensure residents are reposititioned safely by staff to avoid injury, to include an in-service training on repositioning. Licensee to submit POC by POC due date 4/25/2026.
8
9
10
11
12
13
14
Based on observation, record review and interview, R1 sustained an injury to the top of his/her head when being repositioned by S7 on 11/14/2025 which poses an immediate health, safety and personal rights risk to persons 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.
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)
Page: 3 of 3