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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602144
Report Date: 12/29/2022
Date Signed: 12/29/2022 04:55:33 PM


Document Has Been Signed on 12/29/2022 04:55 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:E & E SUNSHINE MANOR IIFACILITY NUMBER:
197602144
ADMINISTRATOR:ERNESTO O. LUCCONFACILITY TYPE:
740
ADDRESS:740 NORTH PARISH PLACETELEPHONE:
(818) 842-9577
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY:6CENSUS: 4DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Jaime VillanuevaTIME COMPLETED:
04:59 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required One (1) year - infection control Inspection to this facility. Upon arrival, LPA met with staff Jamie Villanueva who assisted with the visit. Administrator was not available due to personal emergency . 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, observed food supply and measure the water temperture which was within range of 105 - 120 degrees F.
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.

The following were observed/inspected:



· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPA was not screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not have designated isolation room as all residents have private rooms.
· Rooms, common areas, bathrooms, and outdoor physical plant was inspected..
· Zero (0) centrally stored client medication records were reviewed on this visit.
· Staff responsible for direct care and supervision were observed wearing masks.
· Residents did not wear mask in their private rooms.
· Emergency non-perishable foods for 7 days were observed. Perishable food for 2 days was observed.

Deficiencies cited, please see 809D for details. Due to lack of time, LPA will return to complete annual at later day.

Exit interview conducted with Jamie Villanueva and copy of report and appeal rights provided

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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Document Has Been Signed on 12/29/2022 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).




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 in 3 0f 3 counts. Administrator Josefina Lacsamana, DSP Lorna Ungad and relative of caregiver Jaon Lingad did not have background clearance or associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Licensee will obtain background clearance paperwork and associate the 3 persons mentioned above and send proof to LPA by POC 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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