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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801931
Report Date: 06/30/2023
Date Signed: 06/30/2023 05:44:20 PM

Document Has Been Signed on 06/30/2023 05:44 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNSHINE HEALTH PLACE 2FACILITY NUMBER:
565801931
ADMINISTRATOR:SAM MARONFACILITY TYPE:
740
ADDRESS:1482 NORMAN AVENUETELEPHONE:
(805) 304-5960
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
06/30/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Cilva ToumeTIME COMPLETED:
05:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 05/23/2023. The LPA met with staff at 2:32 PM and explained the reason for the inspection. The Administrator was contacted an informed of the inspection. Administrator Cilva Toume arrived during the inspection.

During today's inspection the LPA conducted a physical plant tour and reviewed facility records. The LPA reviewed records for five residents. Files were reviewed for but not limited to admission agreements, medical assessment, needs and service plans, and physician orders. Resident #1 (R1) has a diagnosis of dementia and has a medical assessment older than one year (2/18/2022). Resident #2 (R2) has a needs and service plan older than one year on file (05/09/2021). Files were otherwise complete.

The LPA reviewed four staff files for but not limited to, criminal record clearance, personnel records, physicals, and training records. Files reviewed were complete.

During the physical plant inspection, the LPA observed all five residents had half bed rails. One out of the five residents did not have a physician order on file for the rails.

Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiencies was observed and cited during the visit. See LIC 809-D. Exit Interview conducted and the report was reviewed with the Silva Toume. Appeal Rights and a copy of this report has been issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
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 06/30/2023 05:44 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 06/30/2023 at 05:14 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE HEALTH PLACE 2
FACILITY NUMBER: 565801931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)

87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of five residents (Resident #1) needed an updated medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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The Administrator agrees to submit proof that R1 has an updated medical assessment to CCL by 07/14/2023.
Type B
Section Cited
CCR
87463(c)
87463 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 comply with the section cited above in one out of five residents (Resident #2) had an appraisal older than one year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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The Administrator agrees to submit proof of an updated appraisal for R2 to CCL by 07/14/2023.
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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2023 05:44 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 06/30/2023 at 05:25 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE HEALTH PLACE 2
FACILITY NUMBER: 565801931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of five residents with a half bed rail did not have an order on file (Resident #2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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The Administrator agrees to get an order for R2's half bed rail and submit to CCL by 07/14/2023.
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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023


LIC809 (FAS) - (06/04)
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