195850090-10-16-2023-29-AS-BBAI-CWNULF-20231016154042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850090
Report Date: 10/16/2023
Date Signed: 10/16/2023 03:41:38 PM

Document Has Been Signed on 10/16/2023 03:41 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 BALBOA		FACILITY NUMBER:	195850090
ADMINISTRATOR:	JOSE, OYINLOYE AUSTINE		FACILITY TYPE:	735
ADDRESS:	7431 JELLICO AVENUE		TELEPHONE:	(818) 274-1809
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY: 4		CENSUS: 4	DATE:	10/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Oyinloye Austine		TIME COMPLETED:	04:00 PM

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	Licensing Program Analysts (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:20am. Upon arrival LPA met with Administrator Joseph Jose and explained the reason for the visit. At approx. 01:00pm, LPA 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. Facility is a single-story residence and consists of a total of four (4) bedrooms and two (2) bathrooms. During physical plant tour LPAs observed the required postings throughout the facility. The kitchen appeared to be clean and the appliances and fixtures functional during the time of visit. LPAs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked cabinet underneath the sink. Cleaning supplies were also observed stored under the sink. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Hallway closest near Room #3 was observed to be inaccessible to clients in care. LPA observed the closet to store PPE supplies, emergency food supplies, cleaning supplies, and other items for facility use. The hallway closet nearest bedroom #4 was observed to store a sufficient supply of linen. LPA observed bathrooms to be clean, properly supplied and had functional fixtures. LPA observed non-skid mats. The hot water was measured in each bathroom between 111 - 115 degrees Fahrenheit LPA observed the common areas. These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. . Medications are stored in a locked cabinet next to the fire place. LPA observed it to be inaccessible to residents in care. There is a dedicated area for the posting of required documents directly by the entry way. There is a fireplace in the living room that is non-operable at this time. It is screened and there are no tools.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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: 10/16/2023

NARRATIVE

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The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Common room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed fully charged and purchased in September 2023.

The exterior passageways were clean and clear of any obstructions. The entire property is not fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. The gate in the backyard has a self-latching mechanism for persons to enter the front courtyard. LPA observed appropriate furniture for outdoor use. There is no attached garage. There are no bodies of water on the premises at the present time. The laundry area in the rear of the facility. LPA observed it to be inaccessible to clients in care. There is an extra fridge at this location. LPA observed it to store extra perishable food for staff and clients.

Records review began at approx. 1:30pm, five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. At approx. 2:00pm, four (4) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were observed to be in order at this time. Last emergency drill was conducted on 09/06/2023

Medications: Medications review began at approximately 02:45pm. The medications are centrally stored in a locked storage cabinet near the office area. Medications were observed to be properly documented on the centrally stored medications and destruction record.

Continued on 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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: 10/16/2023

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Infection Control : Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate 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 or relocate residents if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Between 1pm - 3:00pm the LPA interviewed four (4 ) staff members and three (3) residents.

LPAs obtained the following documents - Census, Staff schedule, and updated Limited Liability insurance.

Exit interview conducted, appeal rights discussed and a copy of the report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC809 (FAS) - (06/04)

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