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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804203
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:23:52 PM

Document Has Been Signed on 09/06/2024 03:23 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SUNSHINE PETALUMA CARE HOMEFACILITY NUMBER:
496804203
ADMINISTRATOR/
DIRECTOR:		CUEVAS, ELIAFACILITY TYPE:
740
ADDRESS:804 ELY SOUTH BLVDTELEPHONE:
(707) 364-7247
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 2DATE:
09/06/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Roxana Galo Murillo, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 9/6/2024, Licensing Program Analyst (LPA) Hansen conducted an unannounced post licensing inspection for this facility and was welcomed by staff Magela who contacted by telephone Licensee Roxana Galo that arrived shortly after. Administrator Elia Cuevas was unable to attend. This RCFE facility with the capacity of 6 nonambulatory, currently provides care for two (2) residents one of which with a diagnosis of dementia and neither of which are receiving hospice services. Facility has an approved Hospice Waiver for 2.

At approximately 8:35 AM LPA conducted tour of the facility with staff, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. The one Fire Extinguisher was found to be last serviced on 8/21/2023 at the time of the visit and reading is not showing fully charged (see TA LIC 9102). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. When LPA entered facility at 8:30 AM observed (see pics) door with signal turned off and propped open from kitchen to garage where toxins and cleaning supplies are stored in cabinet in garage with locks that do not work as well as window cleaner in unlocked cabinet under kitchen sink all accessible to residents in care (see pics & LIC809-D). There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. LPA tested 6 smoke alarms and 2 carbon monoxide detector and were all found to be in working order. Medication and file storage is stored in a secured cabinet located in Administration area adjacent to the kitchen. Working auditory alarms are placed on all exits.



Continued on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 09/06/2024 03:23 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/06/2024 at 12:06 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SUNSHINE PETALUMA CARE HOME
FACILITY NUMBER: 496804203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with Licensee, they have not obtained the required liability Insurance to operate an RCFE which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee to obtain appropriate liability insurance of 1 million per occurance and three million in the total annual aggregate for facility and submit copy to CCL by 9/20/2024 to clear citation. If extension is needed Licensee will contact LPA.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in observing door with signal turned off and propped open from kitchen to garage where toxins and cleaning supplies are stored in cabinet in garage with locks that do not work as well as window cleaner in unlocked cabinet under kitchen sink all accessible to residents in care which poses/posed a potential health, safety or personal rights risk to persons in care. Signal system turned on and door locked by Licensee.
POC Due Date: 09/20/2024
Plan of Correction
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An In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Training with dates and signatures of staff to be submitted by due date of 9/20/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SUNSHINE PETALUMA CARE HOME
FACILITY NUMBER: 496804203
VISIT DATE: 09/06/2024
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File Review began at 9:35 AM:
A sample review of two residents & three staff records as well as two resident’s medications was conducted.
LPA learned that 2 out of 2 residents have updated Appraisals as well as medical assessments. As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions; In addition, Direct care staff have received the additional training requirements although are not logged (see LIC9102 TA); LPA was also provided required proof of CPR & 1st Aid certification.

Medication Audit began at 11:15 AM:
Medications were centrally stored in locked cabinet in Admin area adjacent to kitchen. LPA observed medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to have all medications entered for residents.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have not been conducted Technical Advisory given, although should be conducted quarterly and in different shifts. Facility has not obtained required Liability Insurance and is being cited today (see LIC809-D).

Administrator Certificate for administrator Elia Cuevas # 6057784740 expires 1/4/2025.



Appeal Rights Given.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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