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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700093
Report Date: 10/09/2024
Date Signed: 10/09/2024 11:55:17 AM


Document Has Been Signed on 10/09/2024 11:55 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 13DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Caregiver Rosa HernandezTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPA) Lavinia Muscan arrived unannounced on 10/9/24 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA and Caregiver Rosa Hernandez toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguishers are ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed.

LPA reviewed resident (4) and staff files (3). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month.

Exit interview conducted. A copy of this report was printed and given to staff.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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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