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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850090
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:02:24 PM

Document Has Been Signed on 10/29/2024 03:02 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: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:34 AM
MET WITH:Jose OyinloyeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:34 AM. LPA met with facility staff who contacted facility backup administrator Toluwalope Adefemiwa via telephone call. Facility backup administrator arrived to the facility at 09:42 AM Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:35 AM, the LPA, along with facility staff 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:

BEDROOMS: There are four (4) bedrooms in the facility; all are designated for resident use. All four (4) bedrooms are private rooms. LPA and facility staff toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

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 at 12:08 PM 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.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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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: 10/29/2024
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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 05/2024. At 10:02 AM LPA observed the kitchen window and door to be broken. LPA spoke with the facility administrator who stated that they were broken during the outburst of a client and are scheduled to be repaired later today (10/29/2024).

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. The water temperature was measured in both bathrooms between 105.4 degrees Fahrenheit and 107.6 degrees Fahrenheit which is in compliance with regulation.

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 resident use. LPA observed an appropriately secured outdoor room to contain the facility’s washer and dryer, an additional refrigerator containing resident medication, and extra cleaning supplies.



RECORD REVIEW: Record review began at 10:10 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained the required documents and trainings. Four (4) resident files were reviewed. All resident files contained all required documentation and signatures.

MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication review began at 11:44 AM. Medications are stored centrally and securely in a storage cabinet in the living room. Medications for four (4) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. Cash resources were reviewed for three (3) residents, all cash resources observed were documented properly with the corresponding receipts. No deficiencies were observed during cash resource review.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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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: 10/29/2024
NARRATIVE
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INFECTION CONTROL / EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 07/03/2024. The facility’s emergency disaster plan was updated on 04/01/2024 and is adequate.

INTERVIEWS: LPA interviewed two (2) residents and two (2) staff members. One (1) resident interviewed stated that the facility is fun, the staff are nice, and that they have no concerns with the facility. Both staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During record review one (1) resident file reviewed revealed that the resident was designated by their physician as non-ambulatory on their physician’s report. LPA reviewed the facility’s fire clearance and observed that they are only cleared to care for four (4) ambulatory residents. LPA informed the facility backup administrator that this is a serious deficiency and a zero-tolerance policy. Because of this an immediate civil penalty in the form of $500 is being assessed on 10/29/2024 for a fire clearance violation. LPA informed the backup administrator that failure to correct the deficiency may result in additional penalties.

During today’s visit LPA obtained a copy of the facility’s updated LIC500, resident roster, surety bond, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/29/2024 03:02 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/29/2024 at 01:53 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: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one (1) resident was identified in their physician's report as non-ambulatory and the facility is licensed to only care for four (4) ambulatory residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee will submit proof of either resident relocation or an updated physician's report indicating the resident's ambulatory status to CCL no later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/29/2024 03:02 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/29/2024 at 01:53 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: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the facility's kitchen window and door were broken which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Licensee will submit proof of completed repairs to the kitchen door and window to CCLD no later thann POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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