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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850090
Report Date: 12/27/2022
Date Signed: 12/27/2022 12:34:31 PM

Document Has Been Signed on 12/27/2022 12:34 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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:
12/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alexis Sias - AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi arrived unannounced to conduct a Case Management - Deficiencies visit at this facility. Upon arrival LPA met with Alexis Sias and explained the reason for the visit.

At approximately 12:00pm, LPA conducted physical plant, areas inside and outside to ensure there are no health and safety hazards. At 12:00pm, LPA reviewed records.

Prior to visit , LPA printed out the facility personnel report summary from the Licensing Information System (LIS). Per record review, conducted by LPA on the Guardian website, Staff 1 (S1) and Staff 2 (S2) and Administrator have criminal record clearance's, but are not associated to this facility.

The Administrator stated that the facility will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to Lice 809-D). Civil penalties assessed in the amount of $500 at this time. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. Report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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Document Has Been Signed on 12/27/2022 12:34 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/27/2022 at 11:51 AM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME BALBOA
FACILITY NUMBER: 195850090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2022
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record... residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355 C …

This requirement is not met as evidenced by:
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Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 12/27/2022. Licensee will submit proof of clearance to LPA via email by eod 12/27/2022.
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Based on record review and interview the licensee did not comply with the section cited by not transferring the criminal record clearance for S1, S2 and Administrator to this facility prior to employment which poses an immediate health, safety and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022


LIC809 (FAS) - (06/04)
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