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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609850
Report Date: 06/24/2022
Date Signed: 06/24/2022 12:16:57 PM

Document Has Been Signed on 06/24/2022 12:16 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 MANORFACILITY NUMBER:
567609850
ADMINISTRATOR:TREJO, MIKEFACILITY TYPE:
740
ADDRESS:19 E AVENIDA DE LOS ARBOLESTELEPHONE:
(805) 241-9687
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mike TrejoTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with Administrator Mike Trejo and explained the reason for the visit.

KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The four resident bedrooms had appropriate furnishings, clean linens and sufficient lighting. The LPA conducted a file review and confirmed that bedridden residents were in the appropriate rooms. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. The LPA observed hand hygiene signs in all restrooms. COMMON SPACES: The facility maintained a temperature of 76 degrees. The fireplace was appropriately screened. Living room and dining furniture were observed to be in good condition. Required postings were observed in the kitchen and the front door. The backyard had furniture and a covered area for resident use. There was an in ground swimming pool which was appropriately fenced and locked at the time of the visit.

INFECTION CONTROL: Whereas is a central entry point for universal screening and temperature checks, the staff did not ask the LPA screening questions nor was the LPA’s temperature taken at the time of the visit. When the LPA first arrived, staff and visitors were not wearing appropriate face masks. There were COVID-19 signs that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. There is sanitizer available for use throughout the facility. The facility’s cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19 Staff are up to date regarding guidelines around visitation and vaccine requirements. The Infection Control plan was discussed with the Administrator and it was confirmed that it will be submitted timely. The policies and procedures pertaining to infection control were adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22. Exit interview conducted, a copy of the report and appeal rights were issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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 06/24/2022 12:16 PM - It Cannot Be Edited


Created By: Ashley Smith On 06/24/2022 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE MANOR

FACILITY NUMBER: 567609850

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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, as staff and visitors were not following infection control protocols in wearing masks, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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The Administrator has agreed to do the following:
1. Conduct an in-service training, discussing the masking requirements and screening protocol for visitors. Submit sign-in sheet and applicable documents no later than 06/27/2022.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


LIC809 (FAS) - (06/04)
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