Inspection Reports for Sunshine Villa, A Merrill Gardens Community
80 Front St, Santa Cruz, CA 95060, CA, 95060
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the most recent report on October 7, 2025, showing no deficiencies related to a medication error incident. Earlier reports included some deficiencies primarily involving resident supervision and medication management, such as elopements in late 2024 that resulted in a $500 fine and medication errors in early 2025. Several complaint investigations were unsubstantiated, including allegations about staff neglect, cleanliness, and COVID-19 protocols. The facility has shown improvement over time, with follow-up visits clearing previous deficiencies and recent inspections consistently finding no new issues. Minor or isolated deficiencies related to documentation and care services appeared sporadically but did not persist in the latest inspections.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
83% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 109
Capacity: 132
Deficiencies: 0
Oct 7, 2025
Visit Reason
The inspection visit was an unannounced Case Management Incident visit triggered by a reported medication error discovered on 2025-09-30 involving a medication discontinued in error on 2025-08-15 for Resident R1.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst determined the incident requires further investigation. An exit interview was conducted with the General Manager.
Complaint Details
The visit was complaint-related due to a medication error reported by the facility. The report states the resident's physician and responsible parties were notified. No deficiencies were cited during this visit.
Report Facts
Facility capacity: 132
Resident census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | General Manager | Met with Licensing Program Analyst during the visit and involved in exit interview |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced Case Management Incident visit |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 132
Deficiencies: 0
Aug 1, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection triggered by an incident report received on 08/01/2025 regarding a physical altercation between two residents on 07/31/2025.
Findings
The investigation found that staff intervened during the altercation, no injuries were observed, residents were assessed, and responsible parties were notified. The facility is monitoring the involved residents and has implemented measures to prevent further incidents. No deficiencies were cited during the visit.
Complaint Details
The complaint involved a physical altercation between Residents R1 and R2 on 07/31/2025. The incident was reported, no injuries were observed, and the facility is monitoring the residents involved.
Report Facts
Capacity: 132
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | General Manager | Met with Licensing Program Analyst during the inspection and provided information about the incident |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
Inspection Report
Annual Inspection
Census: 107
Capacity: 132
Deficiencies: 0
Jul 28, 2025
Visit Reason
An unannounced annual inspection was conducted as a required one-year visit to evaluate compliance with licensing requirements.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. The facility was well-maintained, with proper food storage, secure medication and cleaning product storage, functioning safety equipment, and complete resident and staff records.
Report Facts
Water temperature range: 105
Water temperature range: 118
Food supply duration: 2
Food supply duration: 7
Refrigerator temperature: 38
Freezer temperature: -15
Number of resident rooms toured: 10
Number of resident bathrooms toured: 10
Number of resident records reviewed: 5
Number of medication records reviewed: 3
Number of staff records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | General Manager | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced annual inspection |
Inspection Report
Census: 105
Capacity: 132
Deficiencies: 0
May 29, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted regarding an incident that occurred on 2025-05-27, following receipt of an Incident Report on 2025-05-28.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst determined that the case management requires additional review and information.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Spears | Health Services Director | Met with during the inspection and involved in the incident discussion. |
| Candace Bolin | Administrator/Director | Named as General Manager who was out sick during the visit. |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
Inspection Report
Follow-Up
Census: 101
Capacity: 132
Deficiencies: 0
Apr 23, 2025
Visit Reason
The visit was an unannounced Plan of Correction (POC) follow-up to review deficiencies cited on 2025-04-04 related to two elopements reported in December 2024.
Findings
The facility provided documentation of staff training on elopement and related topics conducted on 2025-04-16 and 2025-04-23. The Licensing Program Analyst cleared the previously cited deficiencies during this visit, and no new deficiencies were cited.
Report Facts
Staff count: 48
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | General Manager | Met with Licensing Program Analyst during the visit and involved in Plan of Correction |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced POC visit and cleared deficiencies |
| Manuel Monter | Licensing Program Analyst | Conducted the initial Case Management visit on 2025-04-04 |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 132
Deficiencies: 2
Apr 4, 2025
Visit Reason
The visit was an unannounced Case Management-Incident inspection regarding two elopements that occurred on 12/8/2024 and 12/15/2024 involving residents R1 and R2.
Findings
The investigation found that residents R1 and R2, both with neurocognitive disorders and wandering behaviors, left the facility unassisted and were returned by local law enforcement. The facility staff failed to redirect the residents and were unaware of one elopement, posing immediate health, safety, and personal rights risks. An immediate civil penalty of $500 was issued for absence of supervision.
Complaint Details
The visit was complaint-related due to two elopements by residents R1 and R2. The complaint was substantiated with findings that the facility failed to provide adequate supervision and redirection to prevent elopements.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents R1 and R2 left the facility unassisted and were returned by local law enforcement, posing immediate health, safety, and personal rights risks. | Type A |
| Facility staff did not redirect R1 and R2 when they eloped and were unaware of R2's elopement, posing immediate health, safety, and personal rights risks. | Type A |
Report Facts
Civil penalty amount: 500
Number of residents present: 105
Total licensed capacity: 132
Number of elopements investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | Administrator | Met with Licensing Program Analysts during inspection and involved in interviews regarding elopements. |
| Marcella Tarin | Licensing Program Analyst | Conducted interviews and authored the inspection report. |
| Jin Jackie | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 132
Deficiencies: 0
Mar 20, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility staff did not ensure that residents’ rooms are clean, safe, and sanitary at all times.
Findings
After interviews with staff, residents, and a tour of multiple resident rooms in both assisted living and memory care sections, the Department found the allegation to be unsubstantiated. Most staff and residents reported no issues with cleanliness, and the rooms observed were clean, safe, and sanitary.
Complaint Details
The complaint alleged that residents’ rooms were often not cleaned properly, with issues such as feces in or on the toilet, trash on the floor, and beds not being made regularly. The investigation included interviews with staff and residents, and multiple room inspections. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 132
Census: 107
Number of bedrooms toured (assisted living): 26
Number of bedrooms toured (memory care): 11
Number of residents interviewed: 10
Number of staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Marcela Tarin | Licensing Program Analyst | Assisted in conducting the complaint investigation and interviews |
| Candace Bolin | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 132
Deficiencies: 1
Mar 20, 2025
Visit Reason
The visit was an unannounced case management follow-up to investigate a medication error reported in an incident involving Resident R1 on 2025-02-27.
Findings
The investigation confirmed that Staff S1 administered two incorrect doses of medication M1 to Resident R1, resulting in a medication error. A deficiency was issued for failure to meet personnel requirements related to medication administration.
Complaint Details
The visit was triggered by a complaint/incident report regarding a medication error involving Resident R1. Staff S1 admitted to administering two doses of medication M1 without conducting the required medication checks. The complaint was substantiated by the investigation.
Deficiencies (1)
| Description |
|---|
| Based on investigation, on 2/27/2025, Staff S1 administered 2 incorrect doses of medication M1 to Resident R1 which poses an immediate health, safety and personal rights risk to persons in care. |
Report Facts
Medication doses administered: 4
Facility capacity: 132
Resident census: 107
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | General Manager | Met with Licensing Program Analysts during the visit and participated in the exit interview. |
| Marcella Tarin | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Manuel Monter | Licensing Program Analyst | Conducted the inspection. |
| Jin Jackie | Licensing Program Manager | Supervisor overseeing the inspection and named in the report. |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 132
Deficiencies: 0
Mar 6, 2025
Visit Reason
The visit was conducted as a Case Management - Incident investigation following an incident report received on 3/5/2025 regarding bruising observed on Resident R1.
Findings
The investigation found that the discoloration on R1's neck was green dye transferred from necklaces worn during a Mardi Gras event, which was wiped away. Bruising under R1's left eye was observed with an unknown cause. The facility plans to increase monitoring and staff training on recognizing bruising and discoloration.
Complaint Details
The visit was complaint-related due to an incident report of bruising on Resident R1. The bruising on the neck was determined to be dye transfer and not an injury, but bruising under the left eye was unexplained. The facility sought medical care and informed all responsible parties and the physician.
Report Facts
Staff interviewed: 7
Visit start time: 1030
Visit end time: 1315
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | General Manager | Met with Licensing Program Analyst during the visit and involved in incident discussion |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 132
Deficiencies: 0
Feb 20, 2025
Visit Reason
The visit was an unannounced Case Management-Incident inspection regarding two elopements that occurred on 12/8/2024 and 12/15/2024.
Findings
LPAs toured and tested exit doors related to the elopements, interviewed staff and the administrator, and requested additional documentation and security video footage. Due to insufficient information, the investigation requires further review.
Complaint Details
The investigation was triggered by two elopements. Interviews were conducted with staff and the administrator, but one resident declined to be interviewed. Additional documentation and video footage were requested. The investigation remains open due to insufficient information.
Report Facts
Number of elopements: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | Administrator | Met with LPAs during the inspection and named in the report |
| Marcella Tarin | Licensing Program Analyst | Conducted the inspection |
| Manuel Monter | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Census: 105
Capacity: 132
Deficiencies: 0
Dec 19, 2024
Visit Reason
The visit was an unannounced Case Management inspection to follow up on two incident reports involving two resident elopements from the facility.
Findings
The inspection found that 13 out of 13 alarmed exit doors were functioning properly. The investigation is ongoing due to insufficient information, requiring additional review.
Report Facts
Number of alarmed exit doors: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candace Bolin | Administrator | Met with Licensing Program Analysts during the inspection and discussed the purpose of the visit. |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Kenneth Madrigal | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 132
Deficiencies: 0
Dec 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations that facility staff did not respond to emails of complaints from family members and that the facility lacked directors of health service and resident service to manage and supervise caregivers.
Findings
The investigation found no evidence to support the allegations. Interviews with staff, residents, and family members indicated that the facility responded to complaints and that the absence of two directors did not impact care and supervision. The complaint was unsubstantiated and no citations were issued.
Complaint Details
The complaint was received on 2024-05-22 with allegations that staff did not respond to family member complaints and that the facility lacked directors to manage caregivers. The investigation included interviews with the administrator, staff, residents, and family members. The findings were unsubstantiated.
Report Facts
Facility capacity: 132
Census: 102
Number of staff interviewed: 10
Number of residents interviewed: 8
Complaint receipt date: May 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candi Bolin | Administrator | Interviewed regarding complaint response and facility operations |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced investigation visit |
| Chihhsien Chang | Evaluator / Licensing Program Analyst | Conducted complaint investigation and signed report |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 132
Deficiencies: 0
Nov 9, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following allegations that staff do not provide proper assistance to residents in care.
Findings
The investigation included interviews with residents and staff and a review of records. No concerns were expressed by residents, and staff denied the allegations. The complaint was found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff do not provide proper assistance to residents in care. The investigation found the allegations unsubstantiated based on interviews and evidence gathered.
Report Facts
Capacity: 132
Census: 107
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 132
Deficiencies: 0
Nov 9, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations regarding staff practices, including restrictions on medical professional visits without COVID testing, assistance with incontinence care, meal provision, and response times to call lights.
Findings
The investigation included interviews, observations, and record reviews. All allegations were found to be unsubstantiated as evidence and interviews did not corroborate the claims. Residents and staff denied the allegations, and records showed compliance with CDC guidelines and timely care.
Complaint Details
The complaint investigation was triggered by allegations that staff were not allowing medical professionals or family visits without a 24-hour COVID test, not assisting residents with incontinence care timely, not feeding residents, and not responding promptly to call lights. The investigation found no preponderance of evidence to substantiate these allegations.
Report Facts
Census: 107
Total Capacity: 132
Response time range (seconds to minutes): Call light response times ranged from 22 seconds to 57 minutes
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Gleitsmann | Community Relation Assistant | Met with the Licensing Program Analyst during the investigation |
| James McKie | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 132
Deficiencies: 1
Nov 9, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that the facility was not following COVID-19 protocols, staff were not answering residents' call buttons timely, residents were not getting medications timely, and residents were not getting showers timely.
Findings
The investigation found the allegations regarding COVID-19 protocols, call button response times, and medication administration to be unsubstantiated. However, the allegation that residents were not receiving showers timely was substantiated due to discrepancies in shower logs for one resident, indicating the facility was not meeting hygiene needs.
Complaint Details
The complaint investigation was triggered by allegations received on 01/18/2022 regarding failure to follow COVID-19 protocols, untimely response to call buttons, untimely medication administration, and untimely showers. The COVID-19, call button, and medication allegations were found unsubstantiated. The shower allegation was substantiated based on review of shower logs and interviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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 evidenced by failure to ensure Resident 1 received showers as scheduled. | Type B |
Report Facts
Census: 107
Total Capacity: 132
Shower frequency for Resident 1: 2
Shower frequency for Resident 1: 2
Shower frequency for Resident 1: 1
Call button response time range (seconds to minutes): Response times varied between 22 seconds and 57 minutes
Plan of Correction Due Date: Nov 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
| James McKie | Administrator | Facility administrator named in the report |
| Jennifer Gleitsmann | Community Relation Assistant | Met with Licensing Program Analyst during the inspection |
| Candi Bolin | Administrator who clarified shower log documentation | |
| Tasha | Participated in exit interview | |
| Melissa | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 132
Deficiencies: 0
Nov 9, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff were not safeguarding residents' personal property and were not preventing residents from being victims of financial abuse by an unknown perpetrator.
Findings
The investigation involved interviews with residents and staff and a review of records. All interviewed residents and staff denied the allegations, and no evidence was found to corroborate the claims. The complaint allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to safeguard residents' personal property and failure to prevent financial abuse. Interviews with 7 residents and 3 staff members, as well as record reviews, did not support the allegations.
Report Facts
Census: 107
Total Capacity: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 132
Deficiencies: 0
Nov 9, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that facility staff neglected to assist residents during falls and that the facility was not quarantining COVID-19 positive residents.
Findings
The investigation found no corroboration for the allegations after interviews with residents and staff and review of facility plans and records. Both allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was triggered by allegations of neglect in assisting residents during falls and failure to quarantine COVID-19 positive residents. The allegations were found to be unsubstantiated based on interviews with 7 residents and 3 staff members, review of the fall prevention plan and COVID-19 mitigation plan, and evidence collected during the investigation.
Report Facts
Capacity: 132
Census: 107
Number of residents interviewed: 7
Number of staff interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Gleitsmann | Community Relation Assistant | Met with the Licensing Program Analyst during the investigation |
| James McKie | Administrator | Facility administrator named in the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 132
Deficiencies: 0
Sep 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including staff neglect resulting in the death of a resident, failure to follow medication orders, failure to safeguard resident's personal belongings, and failure to maintain a comfortable temperature for residents.
Findings
The investigation found that although some allegations may have occurred or be valid, there was not a preponderance of evidence to prove any violation did or did not occur. The allegations were therefore unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff neglect leading to a resident's death, medication errors by staff, theft of resident's valuables, and inadequate temperature control. The facility took some corrective actions such as banning a resident assistant and providing portable air conditioners upon request, but no violations were substantiated.
Report Facts
Facility capacity: 132
Census: 102
Complaint receipt date: Jun 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Candi Bolin | Executive Director | Met with Licensing Program Analyst during the investigation |
| James McKie | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 132
Deficiencies: 2
Sep 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-14 regarding medication administration errors and delayed staff response to resident requests at Sunshine Villa Assisted Living and Memory Care.
Findings
The investigation substantiated that staff delivered the wrong insulin to resident R1 on 2023-11-09 and delayed delivering the correct insulin for over an hour, failing to meet resident health needs. Additionally, staff were found insufficiently trained and not competent in medication administration. Another complaint regarding staff response to resident communication requests and participation of resident's representative in care decisions was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure resident R1 was administered medications as prescribed, specifically delivering wrong insulin and delaying the correct insulin administration by over an hour on 2023-11-09. The complaint that staff did not respond timely to resident communication requests and did not ensure resident's representative participation in care decisions was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, specifically related to insulin and medication management. | Type B |
| Facility staff failed to provide care, supervision, and services that meet individual resident needs due to insufficient numbers, qualifications, and competency. | Type B |
Report Facts
Capacity: 132
Census: 102
Deficiency due date: Sep 18, 2024
Dates of wrong insulin administration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation |
| James McKie | Administrator | Facility administrator named in the report |
| Candi Bolin | General Manager | Met with Licensing Program Analyst during investigation and exit interview |
| S1 | Staff member who delivered wrong insulin to resident R1 on 2023-11-09 | |
| Resident Care Director | Resident Care Director | Interviewed during investigation regarding resident care and communication |
| Health Service Director | Health Service Director | Interviewed during investigation regarding resident care and communication |
Inspection Report
Annual Inspection
Census: 94
Capacity: 132
Deficiencies: 2
Jul 18, 2024
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements at Sunshine Villa Assisted Living and Memory Care.
Findings
The inspection found deficiencies related to failure to submit an incident report for a resident fall and incomplete medication records lacking start dates in the centrally stored medication log. The facility was otherwise inspected for safety, food storage, and environmental conditions with no obstructions noted.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit a written incident report to the licensing agency for resident R3's fall on June 1, 2024. | Type B |
| Medication start dates for medications M1-M7 for resident R1 and M1-M4 for resident R2 were not listed in the centrally stored medication log. | Type B |
Report Facts
Residents in Assisted Living: 88
Residents in Memory Care: 6
Deficiencies cited: 2
Fire extinguisher last serviced: Sep 6, 2023
Sprinkler system last maintenance: Jun 27, 2024
Last fire/earthquake drill: May 18, 2024
Room temperature: 70
Hot water temperature: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James McKie | Administrator | Facility Administrator mentioned as being on vacation during inspection and responsible for plans of correction. |
| Sharon Carollo | Head Nurse | Met with during inspection and reviewed findings. |
| Manuel Monter | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Romeo Manzano | Licensing Program Manager | Supervisor overseeing the inspection. |
| Hilda Bejar | Staff | Staff member who accompanied the LPA during the facility tour. |
| S2 Sharon Carollo | Staff | Reviewed report with LPA and discussed deficiencies. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 132
Deficiencies: 1
Oct 24, 2023
Visit Reason
The inspection was conducted as a case management incident visit following a notice received on 10/06/2023 that a resident (R1) left the facility without notice on 10/01/2023 and was returned the same day by the spouse.
Findings
Deficiencies were noted related to personnel requirements, specifically that facility personnel were not sufficient in numbers and competent to meet resident needs, as evidenced by the incident involving resident R1 leaving without notice and returning after 6:00 PM the same day.
Complaint Details
The visit was complaint-related due to a report that resident R1 left the facility without notice on 10/01/2023 and was returned by the spouse the same day. The complaint was investigated during the visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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 resident R1 leaving the facility without notice and returning after 6:00 PM the same day. | Type A |
Report Facts
Capacity: 132
Census: 90
Deficiency count: 1
Plan of Correction Due Date: Oct 25, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James McKie | Administrator | Facility administrator named in the report header |
| Candi Bolin | General Manager | Met with Licensing Program Analyst during the visit |
| Daris Duong | Health Services Director | Met with Licensing Program Analyst during the visit and involved in deficiency review |
| Steve Chang | Licensing Program Analyst | Conducted the inspection visit |
| Romeo Manzano | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 132
Deficiencies: 1
May 12, 2023
Visit Reason
The inspection was conducted as an unannounced case management investigation in response to an incident report regarding the elopement of a resident on 02/24/2023.
Findings
The facility failed to ensure staff attempted to redirect the resident from leaving unassisted, posing an immediate health and safety risk. The resident was found outside the community by a pedestrian and returned by the responsible person. The facility is installing delayed egress devices to prevent future elopements.
Complaint Details
Case management was initiated due to an incident report of a resident elopement on 02/24/2023. The resident was not permitted to leave unattended and was found outside the community. The facility did not detect the elopement during peak hours despite staff monitoring exits.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not attempt to redirect resident (R1) from leaving the facility unassisted, posing an immediate health and safety risk. | Type A |
Report Facts
Deficiencies cited: 1
Capacity: 132
Census: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the unannounced case management investigation |
| Candi Bolin | Facility Administrator | Met with Licensing Program Analyst during investigation |
| Sarah Yip | Licensing Program Manager | Supervisor and Licensing Evaluator named in report |
Inspection Report
Annual Inspection
Census: 101
Capacity: 132
Deficiencies: 0
Jul 20, 2022
Visit Reason
An unannounced annual inspection was conducted as a required 1-year visit to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and compliant with all regulations. No deficiencies were cited during the visit. Staff and most residents were vaccinated, and appropriate infection control measures were observed.
Report Facts
PPE supply: 30
Food supply: 2
Food supply: 7
Water temperature: 109.7
Facility temperature: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Candi Bolin | Administrator | Met with Licensing Program Analyst during inspection and reviewed report |
| Ryker Heberle | Licensing Program Analyst | Conducted the unannounced annual inspection |
Inspection Report
Annual Inspection
Capacity: 132
Deficiencies: 1
Jul 22, 2021
Visit Reason
An unannounced annual inspection was conducted as a required 1-year visit to evaluate compliance with facility regulations.
Findings
The facility was generally clean, well maintained, and staff were observed wearing masks with most residents and staff vaccinated. However, water temperatures in resident bathrooms exceeded the maximum allowed temperature, posing a potential safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Hot water temperature from sinks in resident restrooms exceeded 120 degrees F, posing a potential risk to residents' personal rights and safety. | Type B |
Report Facts
Hot water temperature: 136.4
Hot water temperature: 140.3
Plan of Correction Due Date: Jul 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tami Ojwang | Administrator | Met with Licensing Program Analyst during inspection and reviewed report |
| Ryker Heberle | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sarah Yip | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 132
Deficiencies: 0
May 6, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 11/25/2020 concerning resident falls, feeding, fluid intake, and incident reporting at Sunshine Villa Assisted Living and Memory Care.
Findings
The investigation included multiple visits, interviews with residents and staff, and review of resident records. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence proving the alleged violations occurred.
Complaint Details
The complaint involved allegations that a resident sustained multiple falls, staff failed to ensure proper feeding and fluid intake, and failed to properly report an incident. The resident central to the complaint had been moved and later passed away. The investigation found no substantiation of the allegations.
Report Facts
Number of residents interviewed: 18
Number of staff interviewed: 16
Facility visits: 4
Resident capacity: 132
Resident census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the complaint investigation and tele-visit |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on report |
| Tami Ojwang | General Manager | Met with Licensing Program Analyst during investigation |
| James McKie | Administrator | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 132
Deficiencies: 0
Apr 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not allowing resident access to a telephone.
Findings
The investigation included interviews with residents and staff, document reviews, and observations. The allegation was found to be unsubstantiated as evidence did not prove that residents were denied telephone access.
Complaint Details
The complaint was received on 01/06/2021 and investigated through multiple visits and interviews. The allegation that the facility did not allow resident access to a telephone was unsubstantiated.
Report Facts
Number of residents interviewed: 18
Number of staff interviewed: 16
Number of resident records reviewed: 9
Number of facility visits: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the complaint investigation |
| Marybeth Donovan | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Tami Ojwang | General Manager | Met with Licensing Program Analysts during the investigation |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 132
Deficiencies: 2
Apr 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations of inadequate staffing and unmet resident care needs at Sunshine Villa Assisted Living and Memory Care.
Findings
The investigation found substantiated deficiencies including insufficient staffing during a COVID-19 outbreak, resulting in residents not receiving timely personal care such as bathing and delayed responses to alarms, posing immediate risks to residents' personal rights.
Complaint Details
The complaint was substantiated based on interviews, observations, and record review. The investigation included multiple visits, interviews with residents and staff, and review of resident records. The facility was found to have inadequate staffing and failure to meet residents' care needs during the COVID-19 outbreak.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Facility did not have sufficient staffing during COVID-19 outbreak. | Type A |
| Personal assistance and care as needed by the resident with activities of daily living such as dressing, eating, bathing was not provided timely. | Type A |
Report Facts
Facility Capacity: 132
Census: 92
Deficiencies cited: 2
Plan of Correction Due Date: Apr 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
| Tami Ojwang | General Manager | Facility representative met during investigation and report review |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 132
Deficiencies: 0
Apr 19, 2021
Visit Reason
The visit was conducted to investigate complaints alleging that the facility retained residents with prohibited health conditions and that residents were not receiving proper medical attention.
Findings
The investigation included multiple visits, interviews with residents, staff, family members, and hospice nurses, and review of resident records. The allegations were found to be unsubstantiated or unfounded, with no evidence of prohibited health conditions or inadequate medical care. No deficiencies or citations were noted.
Complaint Details
The complaint investigation was initiated due to allegations that the facility retained residents with prohibited health conditions and that residents were not receiving proper medical attention. After investigation, the allegation of prohibited health conditions was found to be unfounded, and the allegation of improper medical attention was found to be unsubstantiated.
Report Facts
Number of residents interviewed: 18
Number of staff interviewed: 16
Number of resident records reviewed: 9
Number of facility visits: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the complaint investigation and tele-visits |
| Marybeth Donovan | Licensing Program Analyst | Assisted in conducting the complaint investigation and tele-visits |
| Tami Ojwang | General Manager | Met with LPAs during the investigation and exit interview |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 132
Deficiencies: 0
Apr 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations that staff failed to clean a resident's room, provide clean bedding, left the resident in wet clothing for an extended time, and denied hospice resident visitors.
Findings
After multiple visits, interviews with residents, staff, and medical professionals, and observations, the investigation found the allegations to be unsubstantiated. Resident rooms and bedding appeared clean, residents were well groomed, and hospice visitation was allowed as per facility policy.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to clean resident's room, failure to provide clean bedding, leaving resident in wet clothing, and denying hospice resident visitors. The investigation included four visits, interviews with 18 residents and 16 staff, and review of 9 resident records. No evidence supported the allegations.
Report Facts
Residents interviewed: 18
Staff interviewed: 16
Resident records reviewed: 9
Facility visits: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted complaint investigation and tele-visit |
| Marybeth Donovan | Licensing Program Analyst | Conducted tele-visit to deliver complaint investigation findings |
| Tami Ojwang | General Manager | Met with LPAs during investigation and report review |
| James McKie | Administrator | Interviewed regarding hospice visitation policy |
| Sarah Yip | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 132
Deficiencies: 2
Mar 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations that the facility failed to provide adequate food service and that residents were being barricaded in their rooms.
Findings
The investigation substantiated that meals provided did not meet the modified diets prescribed by physicians for certain residents, and that barricades were erected to block doors of dementia residents, posing immediate risks to personal rights. Another allegation that the facility failed to meet residents' needs was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding inadequate food service and barricading of residents' rooms. The allegation that the facility failed to meet residents' needs was unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Meals provided did not match residents' modified diets prescribed by physicians, posing immediate risk to personal rights. | Type A |
| Barricades were erected in the facility to block doors of dementia residents, posing immediate risk to personal rights. | Type A |
Report Facts
Residents interviewed: 16
Staff interviewed: 13
Family members interviewed: 3
Medical professionals interviewed: 4
Site visits conducted: 4
Virtual visits conducted: 1
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Marybeth Donovan | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Tami Ojwang | General Manager | Met with LPAs during investigation and reviewed report findings |
| Sarah Yip | Licensing Program Manager | Oversaw complaint investigation |
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