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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045003003
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:38:37 PM


Document Has Been Signed on 06/14/2023 02:38 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SUNSHINE ASSISTED LIVING- THE COTTAGEFACILITY NUMBER:
045003003
ADMINISTRATOR:BAKER, JENNAHFACILITY TYPE:
740
ADDRESS:1468 SUN MANORTELEPHONE:
(530) 887-3363
CITY:PARADISESTATE: CAZIP CODE:
95969
CAPACITY:17CENSUS: 15DATE:
06/14/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jennah BakerTIME COMPLETED:
02:50 PM
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06/14/2023 01:00 PM Licensing Program Analyst (LPA) Sarah Benson and Licensing Program Manager (LPM) Lauren Crocket arrived at the facility unannounced to conduct a Pre-Licensing Required inspection. LPA and LPM met with Jenna Baker Administrator and explained the purpose of the visit.


LPA Benson and LPM Crocker with the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to sixteen (16) resident rooms, common areas, eighteen (18) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a locked closet.

Administrator certificate is current. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 05-25-23, the facility has been conducting drills every month.


THIS FACILITY IS READY TO BE LICENSED.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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