Sunshine Villa Assisted Living and Memory Care

Facility personnel sufficiency and competence

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This was not met as evidenced by: Based on observation, record review and interview, R1 sustained an injury to the top of his/her head when being repositioned by S7 on 11/14/2025 which poses an immediate health, safety and personal rights risk to persons in care.

Dignity in personal relationships

87468.1 Personal Rights of Residents in All Facilities (a) (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, S8 stated to S2 that he/she told R1 on 11/23/2025 to say ‘please’ before S8 moved out of the way for S1 to fill a water bottle.” This poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning...When changes such as... a physical health condition are observed,*continued below* the licensee shall ensure that such changes..are brought to the attention of the resident's physician and the resident's responsible person, if any.This was not met as evidenced by:

Report serious outbreaks and major accidents

87211(a)(2) Reporting Requirements (a) Each licensee shall furnish to the licensing agency...reports......outbreaks, which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours.This was not met as evidenced by: The facility did not report a norovirus outbreak on February 14th, 2025 to the Department, which poses a potential health, safety and personal rights risk to residents in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision... delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews, the facility staff did not re-direct R1 and R2 when they eloped from the facility. Facility staff were also unaware that R2 had eloped from the facility, which poses an immediate health, safety and personal rights risk to resident in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidenced by: Based on record review and interviews, R1 and R2 cannot leave the facility unassisted. Both residents left the facility unassisted and were returned back to the facility by local law enforcement, which poses an immediate health, safety and personal rights risks to residents in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements - General(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needsThis requirement was not met as evidenced by Based on investigation, on 2/27/2025, Staff S1 administered 2 incorrect doses of medication M1 to R1 which poses an immediate health, safety and personal rights risk to persons in care.

Care and supervision as defined by statute and rules

Basic Services 87464(f)(1): Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidence by: Based on interviews, and file review, the licensee did not ensure R1 was received showers. This posed a potential health and safety risk to R1.

Facility personnel sufficiency and competence

87411 - Personnel Requirements - (a) Facilitypersonnel shall at all times be sufficient innumbers, and competent to provide theservices necessary to meet resident needs.This requirement was not met as evidenced by: Based on interviews and records reviewed,staff S1 was not competent or lacked training to deliver/administer correct insulin to residents based on doctor's prescription. This poses health and safety risks to residents in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents...(a) In addition to the 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 as evidenced by: Based on the interviews and records reviewed, the facility staff took longer than one hour to administer the correct insulin to R1.The facility does not have sufficient staff or staff lack training to provide care to residents in care.

Record centrally stored prescriptions and refill data

Based on observation & record review, the licensee did not comply with the section cited above. LPA observed the medication start date for medications M1-M7 was not listed in the centrally stored medication log for resident R1. LPA observed the medication start date for medications M1-M4 was not listed in the Centrally Stored Medication Log for R2. This poses/posed a potential health, safety or personal rights risk to persons in care.

Report specified resident events within seven days

Based on record review, the licensee did not comply with the section cited above. Based on record review, R3 had a fall on June 1, 2024. LPA requested to see documentation showing an incident report was sent to Community Care Licensing. The facility was unable to show documentation showing they submitted an incident report to Community Care Licensing. This poses/posed a potential health, safety or personal rights risk to persons in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met as evidenced: Based on the interviews and documents reviewed, resident R1 left the facility without notice, and R1 was brought back to the facility after 6:00PM on the same day.

Care of Persons with Dementia - (k) The following initial and continuing requirements must be met... (4) ...facility staff shall attempt to redirect a resident who attempts to leave the facility. This requirement is not met as evidence by: Based on interviews and records review, the licensee did not ensure facility staff attempted to redirect resident (R1) from leaving the facility unassisted which poses an immediate Health and Safety risk to persons in care.

Personal assistance and care for required daily activities

87464 Basic Services(f)(4): Personal assistance and care as needed by the resident... with those activities of daily living such as dressing, eating, bathing. This requirement was not met as evidenced by: Based on records review and interviews, facility was unable to provide assistance and showers in a timely manner. This posed an immediate risk to the personal rights of the residents in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements - General(a): Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: Based on records review and interviews, facility did not have sufficient staffing to meet resident's needs during COVID-19 outbreak. This posed an immediate risk to the personal rights of residents in care.

87705 Care of Persons with Dementia (l)(5): Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely. This requirement was not met as evidenced by: Based on records review and public health reporting, barricades were errected in the facility to block doors of dementia residents. This posed an immediate risk to the personal rights of residents in care.

Modified diets for medical necessity

87555 General Food Service Requirements (b)(7): Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Based on records review, interviews, and observation, meals provided did not match R9 and R13's modified diets perscriped by physicians' as outlined in their care plans. This posed an immediate risk to the personal rights of residents in care.