<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850090
Report Date: 08/05/2024
Date Signed: 08/06/2024 04:00:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240731163451
FACILITY NAME:SUNSHINE RESIDENTIAL HOME BALBOAFACILITY NUMBER:
195850090
ADMINISTRATOR:JOSE, OYINLOYE AUSTINEFACILITY TYPE:
735
ADDRESS:7431 JELLICO AVENUETELEPHONE:
(818) 274-1809
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:4CENSUS: 4DATE:
08/05/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Toluwalope JoseTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not ensure staff had a TB clearance before providing care to residents.
Facility staff do not have first aid/CPR training
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 10:45 A.M., Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced initial 10-day complaint visit to this facility. Upon arrival, LPA met with Muslimah “Kenny” Adebisi. Facility Representative, Toluwalope Jose, was contacted and arrived at the facility. At 1:27 P.M., Licensee, Oyewole “Joseph” Jose, arrived at the facility. Entrance interview conducted. Licensee was unable to be at the facility through the entire visit and designated Facility Representative to sign and receive today’s report. Entrance interview conducted.

At approximately 12:05 P.M., LPA reviewed and obtained copies of records pertinent to the allegation. At 12:30 P.M. LPA interviewed, facility representative, staff and at 1:30 P.M. LPA interview Licensee.

Continues on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20240731163451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME BALBOA
FACILITY NUMBER: 195850090
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
CCR
1
2
3
4
5
6
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20240731163451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME BALBOA
FACILITY NUMBER: 195850090
VISIT DATE: 08/05/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 9099

It was alleged that licensee did not ensure staff had a Tuberculosis (TB) clearance before providing care to residents. During the course of the investigation, LPA observed one (1) staff did not to have TB test result on record. Record review and interview conducted revealed Staff #1 (S1) hired in 2022, did not have TB negative test clearance. During the visit, S1 was able to go to clinic and obtain appropriate clearance. LPA reminded licensee and designee to have all staff TB test cleared before working at the facility. Based on the information gathered, the department has sufficient evidence to determine that licensee did not ensure facility staff had appropriate TB clearance prior to employment; therefore, the above allegation is deemed SUBSTANTIATED at this time.

It was also alleged that licensee did not ensure staff had first aid/CPR training. Based on record review, LPA discovered that seven (7) out of twenty-four (24) staff did not have first aid/CPR on record. LPA explained that there should be at least one staff that is first aid/CPR certified on shift, in case of emergency. Therefore, based upon the interviews conducted and the available documentation reviewed, the above allegation is “licensee did not ensure staff had first aid/CPR training” is SUBSTANTIATED at this time.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8 the following deficiencies were observed and cited. Refer to the following LIC 809-D pages for list of deficiencies. Civil penalty issued in the amount of $1,500. Failure to correct deficiencies may result in additional civil penalties.




Exit Interview Conducted. Report was reviewed with Program Direct, and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240731163451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME BALBOA
FACILITY NUMBER: 195850090
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2024
Section Cited
CCR
80065(g)(1)
1
2
3
4
5
6
7
80065(g)(1) Personnel Requirements. Good physical health shall be verified by a health screening, including a test for tuberculosis, performed under the supervision of a physician...seven days after employment or licensure.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
While conducting investigation S1 provided proof of negative test result to licensee.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above as S1 did not have TB test clearance which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
08/19/2024
Section Cited
CCR
85165(f)(7)
1
2
3
4
5
6
7
Emergency Intervention: (7) Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to have all staff first aid trained and will submit proof of training to LPA before POC due date.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above as eight (8) staff does not have first aid on record which poses an potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5