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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700093
Report Date: 11/08/2021
Date Signed: 11/09/2021 10:09:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SUNSHINE MANORFACILITY NUMBER:
092700093
ADMINISTRATOR:MOTUOMANONO SOKIMIFACILITY TYPE:
740
ADDRESS:3112 WASHINGTON STREETTELEPHONE:
(530) 622-3940
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:14CENSUS: 10DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Motu SokimiTIME COMPLETED:
01:00 PM
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Unannounced annual visit utilizing the infection control domain was performed by LPA Michael Smith. Contact with Motu Sokimi.

A review of staff records on 11/8/21 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances.

As a result of this visit, there were no deficiencies. However, 4 technical violations were issued.

Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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