<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200532
Report Date: 07/03/2024
Date Signed: 07/03/2024 12:42:41 PM

Document Has Been Signed on 07/03/2024 12:42 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNSHINE VILLAFACILITY NUMBER:
079200532
ADMINISTRATOR/
DIRECTOR:		QUEZON, ANGELITA AFACILITY TYPE:
735
ADDRESS:1826 OPHIR COURTTELEPHONE:
(925) 229-2735
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 6CENSUS: 2DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Angelita Quezon, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/03/2024 at 10:20 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Angelita Quezon and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of 6 (six). Administrator certificate #6035187735 expires 05/06/2025.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 3 bedrooms are occupied by the clients and 4 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 113.4 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene supplies were available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/04/2024. Emergency Disaster Drill was last posted on . First aid kit was observed to be complete. Fire drill was last conducted on 05/08/2024.

At 10:35 am/pm, 2 of clients’ records were reviewed. At 11:30 am, 4 staff records were reviewed, and 4 of 4 have current first aid training and associated to the facility. A sample of 2 client’s medications were reviewed.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SUNSHINE VILLA
FACILITY NUMBER: 079200532
VISIT DATE: 07/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LIC809-C Continued...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/10/2025:

LIC 500 Personnel Report - Reviewed
LIC 308 Designation of Administrative Responsibility - Reviewed
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond - Reviewed
LIC 610D Emergency Disaster Plan - Reviewed
Liability Insurance - Reviewed

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2