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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801931
Report Date: 06/11/2024
Date Signed: 06/11/2024 04:05:00 PM

Document Has Been Signed on 06/11/2024 04:05 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/
DIRECTOR:		SAM MARONFACILITY TYPE:
740
ADDRESS:1482 NORMAN AVENUETELEPHONE:
(805) 304-5960
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Cilva ToumeTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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
Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:35AM. LPA initially met with facility staff. Licensee Cilva Toume was contacted over the telephone and arrived at 12:37PM. Entrance interview conducted.

Beginning at 12:48PM, the LPA, along with Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher is fully charged and purchased on 05/23/2024. Smoke detectors were tested at 02:39PM, Carbon Monoxide detector was tested at 02:40PM. All were functional at the time of the visit.

BEDROOMS: There are 8 (eight) total bedrooms in the facility; 6 (six) bedrooms are designated for resident use, 1 (one) staff room and 1 (one) room is utilized for storage. The staff room is kept locked and the storage room did not contain any hazardous items. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. LPA observed full bedrails on 2 (two) residents' beds, however these residents (Resident #1 - R1 and Resident #2 - R2) are not on hospice and do not have valid exceptions on file with the Department.

BATHROOMS: There are 3 (three) total bathrooms in the facility. 1 (one) is used for staff, 1 (one) is a private resident bathroom, and 1 (one) is a hallway bathroom designated for shared resident use. Resident restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in shared resident bathroom and measured in compliance with regulation.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 06/11/2024 04:05 PM - It Cannot Be Edited


Created By: Kelly Dulek On 06/11/2024 at 02:41 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: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as the fire door was observed to have a door stop installed and in use, however fire clearance specifies "door stops prohibited" which poses an immediate safety risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
1
2
3
4
Licensee indicated the door will remain closed effective immediately. The door stop will be removed by POC due date and proof of correction will be sent to LPA. LPA advised that if licensee wishes to have the door open, a fire door magnet must be installed and hardwired into the existing smoke detector system. Licensee with communicate with fire inspector if this work is planned.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/11/2024 04:05 PM - It Cannot Be Edited


Created By: Kelly Dulek On 06/11/2024 at 02:41 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: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in as 2 residents (Resident #1 & Resident #2) out of 3 total records reviewed have full bed rails installed on their beds, however neither is on hospice and neither have a valid exception on file which poses a potential personal rights risk to persons in care.
POC Due Date: 06/25/2024
Plan of Correction
1
2
3
4
Licensee will submit physician's orders, LIC 602, and additional supporting documents, along with an exception request to retain Resident #1 and Resident #2 by POC due date.
Type B
Section Cited
CCR
87705(g)
87705 Care of Persons with Dementia (g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as Resident #3 (R3), who has a diagnosis of dementia has personal grooming, hygiene items, as well as ointments and creams stored unlocked in their private restroom and R3's physician's report indicates yes, at risk if allowed direct access to personal grooming and hygiene items which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
1
2
3
4
During today's visit, licensee secured these items. Licensee indicated they plan to obtain a physician's report indicating R3 can safely have access to these items. Licensee understands that all creams must have physician's orders and be secured and maintained inaccessible to residents in care.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2
FACILITY NUMBER: 565801931
VISIT DATE: 06/11/2024
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
clean and properly furnished at the time of the visit. LPA observed a door stop installed on the fire door in the common area leading to the resident bedrooms. Fire clearance indicates "door stops are prohibited." Medications are stored in a locked hallway cabinet.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knives are stored in a locked box in the kitchen.

GARAGE: Garage was observed locked and contained laundry area, locked chemical storage, extra food, supplies, and emergency food and water.

OUTDOOR SPACE: The backyard has a shaded patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear.

RECORD REVIEW: LPA reviewed 3 (three) resident files during today's visit. R1 and R2 do not have valid exceptions on file. Staff files and additional resident files will be reviewed during annual continuation visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan was observed to be complete and updated annually, as required.

MEDICATION REVIEW: Will be observed during annual continuation visit.

INTERVIEWS: During today's visit, LPA interviewed 1 (one) resident. Additional interviews will be conducted during the annual continuation visit.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty issued in the amount of $500. Licensee was informed that failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4