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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700093
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:31:40 PM


Document Has Been Signed on 11/29/2022 03:31 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
CHICO - RESIDENTIAL, 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: 11DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Caregiver, Rosa HernandezTIME COMPLETED:
03:45 PM
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On 11/29/2022 Licensing Program Analyst (LPA) Lavinia Muscan, arrived at the facility unannounced to conduct an annual visit using the infection control tool visit. LPA met with Caregiver, Rosa Hernandez and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured she used hand sanitizer shortly before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Caregiver.

LPA and Caregiver toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, outside area and common restrooms. Facility has a 2 day perishable and a 7 day non-perishable amount of food. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Caregiver completed the infection control domain and facility was found to be in substantial compliance at this time. Facility has 11 residents 5 of which are on hospice.

Administrator agrees to send in LIC500 and liability insurance.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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