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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850090
Report Date: 10/28/2025
Date Signed: 10/28/2025 01:40:45 PM

Document Has Been Signed on 10/28/2025 01:40 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNSHINE RESIDENTIAL HOME BALBOAFACILITY NUMBER:
195850090
ADMINISTRATOR/
DIRECTOR:		JOSE, OYINLOYE AUSTINEFACILITY TYPE:
735
ADDRESS:7431 JELLICO AVENUETELEPHONE:
(818) 274-1809
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 4CENSUS: 3DATE:
10/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:53 AM
MET WITH:Toluwalope AdefemiwaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. LPA met with the administrator Toluwalope Adefemiwa and explained the reason for the visit.
The LPA, along with the designated Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living room, dining room, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. LPA observed the living room to contain all required postings and a couch for resident use. Smoke detectors and carbon monoxide detectors were tested and were functional at the time of the visit. The dining room was observed to be clean and contains adequate seating for resident use. The hallway was observed to contain two (2) properly secured closets. One (1) closet contained extra linens and towels for resident use. One (1) closet contained the facility’s cleaning supplies and pesticides.
BEDROOMS: There are four (4) bedrooms in the facility; all are designated for resident use. All four (4) bedrooms are private rooms. LPA and the Administrator toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured cabinet under the sink to contain knives and cleaning supplies. The LPA observed fire extinguishers throughout the facility to be fully charged and purchased on 04/2025.
Continues on LIC 809C...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/28/2025
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BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a private resident bathroom and one (1) is designated as a common resident bathroom. Bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces.

OUTDOOR SPACE: The facility has one (1) emergency exit gate, LPA observed clear passageways for emergency exit use. The facility has adequate shaded outdoor seating for residents’ use. LPA observed an appropriately secured outdoor room to contain the facility’s washer and dryer. No bodies of water were observed at the time of the visit.



RECORDS: Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications are stored centrally and securely in a storage cabinet in the living room.; medications are labeled and checked for expiration dates. The medications are documented properly on the centrally stored medications and destruction record. Administrator will speak with the pharmacy to ensure that expiration dates are entered accurately in the Centrally Stored Medication and Destruction Record as currently the pharmacy fills out the form. No errors observed during the medication review.



OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There are two side gates for client use and are single-latched. No bodies of water noted. The washer and dryer are inaccessible in a washer and dryer room. Cleaning supplies and disinfectants are kept in locked cabinets.


The LPA reviewed the following documents:
- LIC500 Personnel Report
- LIC9020 Client Roster
- Certificate of Liability of Insurance
_ Surety Bond

No citations were issued. Exit interview conducted. A copy of the report was issued.


NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
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