Sunshine Care Home

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Administrator Frances Grace Reyes, after identifying themselves and stating the purpose of the inspection. This facility serves twenty-one (21) residents 60 and above; twelve (12) ambulatory and (9) non-Ambulatory. LPA was accompanied by Administrator’s Ian Baylon and Administrator Grace Reyes during a tour of the facility. There are two (2) separate buildings at the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. PPE supplies are onsite. No bodies of water are on premises. Passageways were free from obstructions. According to Administrator Reyes, there are no weapons and/or ammunition stored on the premises. All doors were operational. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are locked in a storage room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and Non-skid pads. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were not complete and compliant. All the direct care staff did not have current First Aid certificates and/or First Aide/CPR certificates. Resident records reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted with Administrator Baylon and Administrator Reyes, to whom copies of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to Administrator’s Baylon and Reyes.the state’s words, verbatim · CDSS document, Nov 9, 2023

Allegation investigated: Lack of supervision resulting in client altercation.

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA was met by Administrator, Grace Reyes, introduced herself, and was allowed entry into the facility. LPA met with Ms. Reyes and discussed the purpose of the visit. Investigation consisted of interviews with clients, staff, and outside sources, record review, and a tour of the facility. It was alleged that lack of supervision resulted in a client altercation. Interviews with staff, clients, and outside sources revealed that on or about 8/25/21, Client #1 (C1) and Client #2 (C2) engaged in an altercation which resulted in physical aggression, but no injuries. Interview with C1 and outside sources revealed that C1 and C2 engaged in an altercation after a disagreement regarding cigarettes. This was the first physical altercation between C1 and C2. Interviews with clients and staff revealed staff were in the area when the incident occurred and intervened. C1 and C2 were admonished by facility staff. Review of records Unsubstantiated revealed that both clients are diagnosed with mental health conditions but did not note a history of physical aggression. The Department has investigated the allegation that lack of supervision resulted in a client altercation. Based on evidence obtained through interviews and record review, there is insufficient evidence to corroborate the allegation. Therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Ms. Reyes. Copies of this report and Licensee/Appeal Rights were provided to her at the conclusion of the visit. Her signature on this report acknowledges receipt of copies of the report and rights.the state’s words, verbatim · CDSS document, Aug 30, 2023 · control 08-AS-20210827114550

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual inspection on November 30, 2021. LPA Correia met Administrator Grace Reyes at the front door, identified herself, and was granted entrance into the facility. LPA explained the purpose of the visit to Administrator Reyes and Licensee Ian Baylon, who arrived a short time later LPA Correia accompanied by Administrator Reyes and Licensee Baylon conducted an overall tour of the facility to ensure accordance with the Department’s Infection Control. LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include vaccination tracking, disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment (PPE). LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, ability to quarantine or isolate if necessary and essential health and safety. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and clients as much as possible; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. An exit interview was conducted and this report along with a copy of the Licensee rights (LIC9058 01/16) was emailed to the Licensee with an electronic read receipt as confirmation of documents.the state’s words, verbatim · CDSS document, Nov 30, 2021