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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609352
Report Date: 10/29/2024
Date Signed: 10/29/2024 04:09:57 PM

Document Has Been Signed on 10/29/2024 04:09 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 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: 3DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH: Toluwalope Jose, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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At 1:00 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with staff Nareka Stewart and LPA was granted access to the facility. The Administrator Toluwalope Jose arrived at the facility shortly after and LPA disclosed the reason for the visit. .

LPA and the Administrator toured the facility inside and out. It is a single story building with 4 bedrooms, 2 bathrooms, kitchen, garage, living room, and a back yard. It has an approved fire clearance for 4 non-ambulatory clients. The facility serves Regional Center clients from the North Los Angeles County Regional Center (NLACRC).

MEDICATIONS: LPA observed the medication locked and inaccessible to clients in care in dinning room. There was a complete first aid kit available at the facility.

During medication review of C1's Levetiracetam 500 MG was refilled on 08/06/24 and based on the interview with the Administrator, LPA was informed that the new medication bottle started as of 08/27/24. After review of records and medication bottle, LPA observed the following:

Medication Name: Levetiracetam 500 MG


Date Filled: 08/06/24
Date the fist bottle started: 08/27/24
Number of medications bottles: 4 of 4
Quantity in each bottle: 60
Total medication in four (4) bottles: 240
Prescription order: take 4 tablets by mouth daily.
Last day for all four (4) bottles was on 10/25/24. However, LPA observed one (1) out of four (4) bottles still full with 60 tablets and the second bottle had a remaining of 12 tablets inside. Therefore, it was determined that the facility did not administer R1’s medications as prescribed.
Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352
VISIT DATE: 10/29/2024
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Kitchen: LPA observed an adequate supply of perishable and non-perishable food in the kitchen refrigerator and freezer. The stove and hood were clean. Sharp objects and cleaning solutions were locked below the sink. Staff demonstrated how the magnetic locks worked during the visit. At 1:10 PM, LPA observed a fully charged fire extinguisher hung near the kitchen purchased on 10/29/2024.

Bedrooms: The facility has 4 bedrooms, all of which are private. The exit from Bedroom #3 was unlocked, and the ramp leading out was secure. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. No hazard was observed.

Bathrooms: The facility has 2 bathrooms. The client bathroom contained liquid soap, paper towels, handwashing instruction signs, a trash can with a lid, and a non-skid mat in the shower. The shower was in good condition.

Garage: LPA and the Administrator entered a locked garage. LPA observed detergents, three laundry machines, an additional refrigerator and freezer, extra water, emergency supplies, and client belongings.

Back yard: LPA observed a couch, a table, and a chair under a covered patio area. Both exit gates were unlocked with inward facing latches. Emergency exit paths were free of obstructions. At 1:30 PM, staff tested the dual-functioning smoke and carbon monoxide detector to be functional. Detectors were hard-wired, as LPA heard 3 out of 3 operational during the test. An additional verbal alert sounded during the test.

Between 2:15 PM to 3:15 PM, LPA reviewed records of three (3) clients and two (2) staff. Client and staff records appeared to be complete and updated.



Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiency issued per Title 22.

Exit interview conducted appeal rights explained and copy of this report signed and delivered.


SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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)
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Document Has Been Signed on 10/29/2024 04:09 PM - It Cannot Be Edited


Created By: Huma Rahimi On 10/29/2024 at 03:56 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME 3
FACILITY NUMBER: 197609352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(4)(B)

80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(4) If the client's physician has stated in writing that the client is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the client with self-administration of their PRN medication.
(B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above to ensure that R1’s medication was administered as prescribed. The bottle refilled on 08/06/24 was supposed to be out on 10/25/24. LPA counted extra 72 remaining This poses an immediate health and safety risk to residents in care
POC Due Date: 10/31/2024
Plan of Correction
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Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
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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