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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609352
Report Date: 03/21/2025
Date Signed: 03/21/2025 09:30:35 AM

Document Has Been Signed on 03/21/2025 09:30 AM - 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNSHINE RESIDENTIAL HOME 3FACILITY NUMBER:
197609352
ADMINISTRATOR/
DIRECTOR:		JOSE, OYINLOYE AUSTINEFACILITY TYPE:
735
ADDRESS:17915 HEMMINGWAY STREETTELEPHONE:
(818) 666-5319
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
03/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Toluwalope Jose, Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Huma Rahimi, met with the staff Trishana Thompson, and the Administrator Designee Toluwalope Jose was contacted via phone and LPA explained the reason for the case management visit. The purpose of the case management visit is to address deficiencies observed during the course of complaint # 31-AS20240807101024, by the Investigator Laura Garcia from the Investigation Branch (IB). The deficiency was not alleged but related to the complaint.

The investigation findings revealed that Client #1 (C1) has extensive self injurious behavior; however, it worsened due to unknown reason. The Investigator conducted an interview with the Administrator Designee, and it was revealed that no documentation/notes of body or skin integrity checks of C1 were done. The Administrator Designee also confirmed that on 07/29/2024, C1’s skin was observed to have discoloration; however, the North Los Angeles Regional Center (NLARC) was not notified. Furthermore, the Investigator conducted interviews with the Case Manager (CM) of C1 and Consumer Services Specialist (CSP) from NLARC and was informed that they were not notified about self sustained injuries in a timely manner. The facility also did not modify C1’s Appraisal Needs and Services Plan, Individual Program Plan (IPP), and the Behavioral Plan, and as a result, C1 was taken to the hospital for further evaluation due to more agitation and self-harm. Based on the information gathered during the course of investigation the facility neglected C1 by not seeking timely medical attention. therefore, deficiencies will be issued on LIC 809D.

Appeal rights explained.

Copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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 03/21/2025 09:30 AM - It Cannot Be Edited


Created By: Huma Rahimi On 03/21/2025 at 08:15 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2025
Section Cited
CCR
85075.4(c)

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Observation of the Client. (C) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition,.....
This requirement is not met as evidenced by:
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The Administrator has agreed to have all staff trained on clients’ behavior plan and develop a plan how to ensure clients will receive timely medical care. POC to be submitted to LPA by POC due date.
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Based on the information gathered through interviews the Licensee did not comply with the section cited above by observing C1’s skin discoloration and did not notify C1’s Physician, Reginal Center, and Community Care Licensing in a timely manner which poses/posed a potential health, safety, or personal rights risk to persons in care.
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Type B
03/28/2025
Section Cited
CCR85068.3(a)

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Modification to Needs and Services Plan (a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result.....
This requirement is not met as evidenced by:
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The Administrator has agreed to make sure there is a documented plan in place for all clients and conduct a training for all staff. POC to be submitted to LPA by POC due date.
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not observing a modified IPP or Needs and service to address significant change in C1's needs which poses/posed a potential health, safety, or personal rights risk to persons in care.
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
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