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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200218
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:31:28 AM

Document Has Been Signed on 12/22/2022 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNNY HOMEFACILITY NUMBER:
079200218
ADMINISTRATOR:CALIN NICULESCUFACILITY TYPE:
735
ADDRESS:1612 ENID DRIVETELEPHONE:
(925) 323-4068
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 6CENSUS: 5DATE:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Carolina Merino, Lead StaffTIME COMPLETED:
11:45 AM
NARRATIVE
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On 12/22/22 at 10:40 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Carolina Merino lead staff and explained the purpose of the visit. The administrator was called and designated Carolina to sign off on the report.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan. Cabinet for knives, and central storage for medications were observed with locks. Fire extinguishers were observed fully charge and tags showed serviced 11/08/2022

The following deficiency was observed during the visit:
LPA observed three cans of food to be expired
LPA observed floor cleaner left unlocked under the kitchen sink and accessible to residents


The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/22/2022 11:31 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 12/22/2022 at 11:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SUNNY HOME
FACILITY NUMBER: 079200218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having floor cleaner left unlocked under the kitchen sink which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2023
Plan of Correction
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POC cleared during visit.
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2023
Plan of Correction
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The facility will go through the pantry and throw away expired food. Proof of correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022


LIC809 (FAS) - (06/04)
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