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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209481
Report Date: 07/08/2026
Date Signed: 07/08/2026 03:21:11 PM

Document Has Been Signed on 07/08/2026 03:21 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SUNSHINE FRESNO HOME 3FACILITY NUMBER:
107209481
ADMINISTRATOR/
DIRECTOR:		BROWN, PRECIOUSFACILITY TYPE:
735
ADDRESS:22056 E DINUBA AVETELEPHONE:
(818) 274-1809
CITY:DINUBASTATE: CAZIP CODE:
93618
CAPACITY: 6CENSUS: 3DATE:
07/08/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Facility staff, Rebecca Willson TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sarah Hurt and Kamaldeep Kaur conducted an unannounced annual inspection. LPAs met with Facility staff, Rebecca Wilson. Administrator’s Certification for Trieg’e Surratt expires on07/30/2026. There are currently 3 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Smoke alarms were tested and are operational. The home has a carbon monoxide detector. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA’s observed three fire extinguishers located throughout the facility not within the safety regulation period. Water temperature was tested at 84 degrees, and 78 degrees (below required temperature) The facility is not performing disaster drills as required. Staff 1 and Staff 2’s Personnel record is not available for review. Resident 1’s medical assessment is not complete and updated. Medication review was conducted. Centrally Stored Medication Record og was not complete.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

An exit interview was conducted with staff. Report signed on-site; a copy of this report, 809D with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Kamaldeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/08/2026 03:21 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/08/2026 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUNSHINE FRESNO HOME 3
FACILITY NUMBER: 107209481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 3 residents that are above the age of 60 did not have a medical assessment for the elderly that was complete, i.e. missing diagnoses etc which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
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Administrator/ Licensee agrees to schedule a medical appointment by due date and submit information to CCLD and submit a copy of the medical assessment when completed.
Type A
Section Cited
CCR
80064(a)(3)
80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in 3 out of 3 fire extinguishers were expired on 3/3/2025 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
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Licensee/ Administrator agrees to replace or service fire extinguishers and submit receipts/ photos by due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/08/2026 03:21 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/08/2026 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUNSHINE FRESNO HOME 3
FACILITY NUMBER: 107209481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 5 staff files were not available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2026
Plan of Correction
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Administrator/ Licensee agrees to review all staff files and ensure all staff files are available at the facility and submit proof by due date.
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 out of 3 residents centrally stored medication log was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2026
Plan of Correction
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Administrator/ Licensee agrees to provide in staff training to complete centrally stored medication log and submit photos of the log by due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/08/2026 03:21 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/08/2026 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUNSHINE FRESNO HOME 3
FACILITY NUMBER: 107209481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in last fire drill was conducted on 11/20/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2026
Plan of Correction
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Licensee/ Administrator agrees to conduct fire drill training with all staff and submit records by due date
Type B
Section Cited
CCR
80088(e)(1)

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 bathrooms temperatures were measured at 78.3 and 84.4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2026
Plan of Correction
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Licensee / Administrator agrees to schedule technician services to adjust water temperatures. Administrator will submit receipt/ photos of water temperature within rage by due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Kamaldeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
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