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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850090
Report Date: 08/05/2024
Date Signed: 08/06/2024 03:55:45 PM

Document Has Been Signed on 08/06/2024 03:55 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: DATE:
08/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Toluwalope JoseTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valera Conway conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC # 29-AS-20240731163451). Upon arrival met with Facility Representative, Toluwalope Jose. Licensee, Oyewole “Joseph” Jose, arrived at the facility later during the visit, however, was unable to be present during the entire visit. Licensee designated staff Toluwalope Jose to sign and receive report.

The case management visit is being conducted due to deficiencies observed during the investigation that is unrelated to the complaint allegations. During today’s visit, LPA along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

During today’s visit twenty-four (24) staff’s records were reviewed. LPAs observed one (1) out of twenty-four (24) staff files did not have criminal record clearance. Record review and interview conducted revealed Staff #1 (S1) listed on current LIC 500 was hired on 06/24/2020. Also, LPA observed Staff #2 (S2) and Staff #3 (S3) are fingerprinted cleared but not associated to this facility. S2 was employed by the company in 2020 and S3 was employed by the company in July 2024. The Facility Representative understands that all staff shall obtain appropriate clearance and be associated prior to working and caring for participants.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies and civil penalties were cited (refer to LIC 809-D).



Exit interview conducted, today's reports and appeal rights were reviewed and issued.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2024 03:55 PM - It Cannot Be Edited


Created By: Valeria Conway On 08/05/2024 at 05:26 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
, 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
08/06/2024
Section Cited
CCR
82019(e)(2)

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82019(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(2)Obtain a CA clearance or a criminal record exemption as... This requirement is not met as evidenced by:
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For S1 Licensee will write a statement of understanding aknowledging that S1 can not be present caring for residents untill background check is complete or that S1 doesn't work for facility anymore and remove S1 from LIC 500. Before POC due date
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Based on record reviewed and interviews conducted licensee didn't comply with regulation above by having one (1) emaployee in the roster that are not fingerprinted nor association to the facility
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Type A
08/06/2024
Section Cited
CCR80010(e)(3)

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80010(e)(3)All individuals subject to a criminal record review..section 1522 shall prior to working, residing or volunteering in a licensed facility:(3) Request a transfer of a criminal record clearance as specified in Section 80019(f) This requirement is not met as evidenced by:
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Licensee will associated S2 and S3 immidiately. before POC due date.
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Based on record reviewed and interviews conducted licensee didn't comply with regulation above by having two (2) emaployees in the roster that are not associated
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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: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


LIC809 (FAS) - (06/04)
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