197602144-1-28-2022-28-AS-NMAN-CB4SDP-20220128124729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602144
Report Date: 01/28/2022
Date Signed: 01/28/2022 12:47:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	E & E SUNSHINE MANOR II		FACILITY NUMBER:	197602144
ADMINISTRATOR:	ERNESTO O. LUCCON		FACILITY TYPE:	740
ADDRESS:	740 NORTH PARISH PLACE		TELEPHONE:	(818) 842-9577
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY:	6	CENSUS: 5	DATE:	01/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Ernest Kevin Go		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with staff Villanueva Jamie, who assist with the visit. Shortly after Administrator Ernest Kevin Go arrived to the facility. The purpose of the visit was explained. The facility is licensed to serve 6 (six) non-ambulatory residents ages 60 and over of which 2 (two) may be bedridden. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved.
Facility is located in a residential neighborhood and consists of five (5) bedrooms - one (1) semi-private and four (4) private bedrooms and two (2) bathrooms, living room, dining area, kitchen, laundry room and a detached garage.
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. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask during this visit.

Resident bedrooms and bathrooms were toured. All bedrooms were sanitary and had the required furnished appropriately. Bathrooms have the required grabs bars and non-skid mats. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F.

Continued 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: E & E SUNSHINE MANOR II	FACILITY NUMBER: 197602144
	VISIT DATE: 01/28/2022

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The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. Common areas were observed clean and properly furnished. Smoke and carbon detectors were in good repair. The fire extinguishers observed to be fully charged. Facility is equipped with fire sprinklers.

Residents and staff records were reviewed and appear to be complete. All residents' medications were reviewed. Medications are documented properly and given as prescribed. First aid kit checked and observed complete with first aid manual.

During the tour of the facility, LPA observed that auditory system is operational, notifications and postings noted throughout the facility,

LPA observed the back yard area has a patio area but it is not accessible to residents as there is an accumulation of unused chairs and inoperable appliances that were covered with a blue plastic covering that are obstructing resident's ability to use the seating area located under patio. The front and back yards are both well landscaped.

The following deficiencies are being cited on the LIC 809D, under the title 22 California Code of Regulations.

Exit Interview Conducted, Appeal Rights has also has been discussed and copy of report was issued. .

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: E & E SUNSHINE MANOR II	FACILITY NUMBER: 197602144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the back yard area has a patio area but it is not accessible to residents as there is an accumulation of unused chairs and inoperable appliances that were covered with a blue plastic covering that are obstructing resident's ability to use the seating area located under patio, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/11/2022
	Plan of Correction
1 2 3 4	Administrator will ensure that back yard patio will be cleaned, and the picture will be sent to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC809 (FAS) - (06/04)

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