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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850090
Report Date: 10/19/2021
Date Signed: 10/19/2021 03:18:03 PM

Document Has Been Signed on 10/19/2021 03:18 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: 0DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:JOSE OYINLOYE AUSTINETIME COMPLETED:
03:25 PM
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At 2:22 p.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff, Licensee JOSE OYINLOYE AUSTINE. Currently the facility has no residents. This annual had a specific emphasis on infection control practices and procedures.
Between 2:36 p.m.- 3:15 p.m., LPA along with Licensee 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.

OUTDOOR SPACE: At 2:38 p.m., LPA observed the back patio, which has a covered outdoor area for future resident use. There is a self-latching gate on the side and back of the facility designated for an emergency exits.

KITCHEN: At 2:41 p.m., LPA observed the kitchen/dining area. Knives will be stored in a locked cabinet. Kitchen appliances are in operable condition. The facility will have a sufficient supply of perishable and non-perishable food. At 3:02 p.m., hot water measured at 112.2-degree Fahrenheit.

BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition. At 3:02 p.m., hot water measured at 118.5-degree Fahrenheit.

COMMON AREAS: Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. There is a working facility telephone for future resident use.

Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 BALBOA
FACILITY NUMBER: 195850090
VISIT DATE: 10/19/2021
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Continued from LIC-809

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Between 2:30 p.m. - 3:00 p.m., LPA conducted Infection Control mitigation module with Licensee.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC809 (FAS) - (06/04)
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