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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209025
Report Date: 12/01/2022
Date Signed: 12/01/2022 12:44:27 PM


Document Has Been Signed on 12/01/2022 12:44 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SUNSHINE HOME CAREFACILITY NUMBER:
107209025
ADMINISTRATOR:BABAKHANIFAR, OMIDFACILITY TYPE:
740
ADDRESS:2540 PAUL AVETELEPHONE:
(559) 286-9020
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Omid Babakhanifar, Administrator TIME COMPLETED:
01:00 PM
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On 12/01/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Bayani Almacen, caregiver. Omid Babakhanifar, Administrator was called and arrived shortly. LPA conducted facility tour with Administrator. All five residents were present during the inspection.

Facility staff was observed with mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed COVID-19 related signs and cough etiquette postings in facility.

LPA observed fire extinguisher served date: 12/06/22. Food supply was checked and appeared to be an adequate supply. LPA checked residents’ locked medications and observed a 30-day PPE supplies. Cleaning supplies were stored and locked under kitchen sink. All bathrooms are observed with securely fastened grab bars and non-skid mat. LPA observed bathroom with trash bin with lid. LPA observed hand washing posting by all sinks.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed five bedrooms that are single occupant. The exterior tour was conducted. Side gate was self-closing and free of debris. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 12/07/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, current liability insurance and Current Administrator certificate. A copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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