Sunshine Board & Care

87211(1) A written report submitted to the licensing.. and to the person responsible... (D) Any incident which threatens the welfare, safety or health of any resident... absence of any resident. This requirement was not met as evidenced by: the Administrator not submitting SIR's of any reportable incidents such as absence of residents, threat of residents safety and welfare which poses a health and safety risk to residents in care.

Based on observation, and record review, the licensee did not comply with the section cited above in one (1) out of three (3) staff by not ensuring all staff file are complete with health screening and TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, and record review, the licensee did not comply with the section cited above in two (2) out of three (3) residents in care by not ensuring that all medication was listed on the centrally stored medication log, and all dispensed medication has been properly initialed by staff that dispensed the medication which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above three (3) out of six (6) residents bedrooms and or bathrooms by not ensuring the cleaning supplies were secured and locked which poses an immediate health, safety or personal rights risk to persons in care.

87412 Personnel Records(g)All personnel records shall be maintained at the facility and shall be available to the licensing agency for review...this requirement is not met as evidenced by: The licensee did not comply with the section cited above by not maintaining record of S1's required employment verification, health screening, and training on file for review, which poses a potential health, safety, and/or personal rights risk to residents in care

Based on observations of resident records, the licensee did not comply with the section cited above in nine, 9 out of twelve, (12) resident files containing out of date Physician's Reports (LIC602) which poses a potential health, safety or personal rights risk to persons in care.

87355 CRIMINAL RECORD CLEARANCE (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance ... This requirement is not met as evidenced by Based on observation & file review, licensee failed to ensure S1 was associated to the facility prior to working. LPA observed that S1 was not associated to the facility. This poses an immediate health & safety risk to the residents in care.

87458 Medical AssessmentPrior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This requirement is not met as evidenced by:Based on observations and record reviews, the Licensee failed to ensure resident in care maintained documentation of and were provided an annual medical assessment which poses a potential Health, Safety or personal rights risk to persons in care.

Employees assisting residents with self-administration of medication; training requirements An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. This requirement is not met as evidenced by:Based on observation and file review, Administrator did not ensure that all staff who handle medications for the residents in care were adequately trained to do so. This poses an immediate Health, Safety or Personal Rights risk to persons in care.

(g) Admission agreements shall specify the following: (5) Refund conditions. (C) The licensee shall refund any prepaid monthly fees to a resident or the resident’s representative, if any, as follows: (2) If there is a change of use of the facility pursuant to Section 87224(a)(5). This requirement was not met as evidenced by:Records reviewed show that R1 monthly payment continued from March 2021 through July 2022. Staff and witness interviews confirm that R1 has moved out of the facilty in March 2021.

Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing S1 to work at the facility for four (4) years without a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above by storing and resident's medications in a plastic containers that are not the original prescriptions bottle from the pharmacy which poses an immediate health, safety or personal rights risk to persons in care.

80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents(b) If such a client is accepted for or maintained in care, his/her cash resources, personal property, and valuables not handled by a person outside the facility who has been designated by the client or his/her authorized representative shall be handled by the licensee or facility staff, and shall be safeguarded in accordance with the requirements specified in (c) through (n) below This requirement is not met as evidenced by: Based on observation, interview and record review the licensee did not safeguard R1s cash resources. This is a potential health, saftey and personal rights risks to persons in care.

Additional Personal Rights...in...Facilities: (a) In addition to the rights...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with 1 resident (R1). R1 got into a physical altercation with R2. No mental health treatment was sought or eviction notice enforced. This was an immedaite person rights violation.

Eviction Procedures: (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with one resident (R1). R1 was provided with an eviction notice that only stated "recent misbehavior" with no further details. This was a potential personal rights violation for R1.

Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with one resident (R1). R1 was provided with an eviction notice dated 4/29/20, but Licensing was not provided with a copy of the eviction notice until 6/24/21. This was a potential personal rights violation for R1.

87411 Personnel Requirements Prior to employment or initial presence in the facility, all employees... shall obtain a California clearnace...This requirement is not met as eveidenced by: based on interviews, licensee failed to ensure S3 and S4 were fingerprinted and associated to the facility prior to employment.This is an immediate health and safety risks to the resident in care.

Reappraisals: (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation in at least 1 of 11 residents at the facility (R2). LPA Colvin observed that R2's last appraisal for Needs & Services was done back in 2018. This is a potential health risk to R2.

Basic Services: (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal...either directly or through outside resources. This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with 4 out of 11 residents (R1 - R4). Residents' Physician's Report state assistance is needed with bathing. Staff not providing assistance. This is a potential health risk to R1 - R4.