567609850-7-6-2021-29-AS-SWAR-C4NQC7-20210706120239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609850
Report Date: 07/06/2021
Date Signed: 07/06/2021 02:54:12 PM

Document Has Been Signed on 07/06/2021 02:54 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 MANOR		FACILITY NUMBER:	567609850
ADMINISTRATOR:	TREJO, MIKE		FACILITY TYPE:	740
ADDRESS:	19 E AVENIDA DE LOS ARBOLES		TELEPHONE:	(805) 241-9687
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 6	DATE:	07/06/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Mike Trejo, Administrator		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required annual visit at 09:28 AM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Mike Trejo and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. LPA advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs. Restroom one (1) hot water measured 113 Fahrenheit at 10:31AM. Restroom two (2) hot water measured 112.9 Fahrenheit at 10:33AM.
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 113.1 Fahrenheit at 10:35 AM.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA did not observed required postings in the facility. Administrator stated required posting will be updated and displayed.

Continued on LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

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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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 MANOR	FACILITY NUMBER: 567609850
	VISIT DATE: 07/06/2021

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BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. The garage contains personal belongings to administrator only. The garage is attached to the facility, but is not accessible. There were bodies of water noted. At 09:37 AM LPA observed, body of water, swimming pool gate was unlocked. Caregiver immediately secured it at the time of observation. LPA advised administrator this poses an immediate health and safety risk.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Civil penalties assessed in the amount of $500.00.

Exit interview conducted. Today's reports, civil penalty and appeal rights were reviewed and a copy was emailed to the Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/06/2021 02:54 PM - It Cannot Be Edited

Created By: Salia Walker On 07/06/2021 at 11:03 AM

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 MANOR	FACILITY NUMBER: 567609850
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(e)

Personal Accommodations and Services

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 swimming pool gate was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/06/2021
	Plan of Correction
1 2 3 4	Administrator will cover training with staff to ensure all bodies of water are properly secured at all times. Aministrator will email statement to LPA once training has been administered.

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Salia Walker

LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

LIC809 (FAS) - (06/04)

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