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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610533
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:15:15 PM


Document Has Been Signed on 09/09/2024 03:15 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:J AND G SUNSHINE MANORFACILITY NUMBER:
197610533
ADMINISTRATOR:LACSAMANA, JOSEFINAFACILITY TYPE:
740
ADDRESS:740 NORTH PARISH PLACETELEPHONE:
(213) 435-3508
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY:6CENSUS: 5DATE:
09/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Josefina Lacsamana-AdministratorTIME COMPLETED:
03:15 PM
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On 9/9/2024 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the facility Administrator Josefina Lacsamana. This is a Change of Ownership Application from facility #197602144 to #197610533 to operate a Residential Care Facility for Elderly (RCFE). A Change in Ownership (CHOW) Application to operate a RCFE was received by Community Care Licensing (CCL) on November 30th, 2023. A fire clearance was approved on December 29th, 2023, for five (5) Non-ambulatory and one (1) Bedridden residents for a total capacity of six (6). The smoke alarms and carbon monoxide detectors are hard wired and inter-connected, they were tested and are operational. The facility has four fire extinguishers that were purchased on 1/8/2024 and are located in the common areas.

A tour of the physical plant was initiated at approximately 10:30am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, dining ware to accommodate a maximum capacity of six (6) residents. Knives and other sharps were observed locked in the cabinet next to the kitchen area.

BEDROOMS: The facility has six (6) bedrooms, of which five (5) bedrooms are designated for residents' use and one (1) bedroom for staff use. The applicant furnished all clients' bedrooms with beds, night stands, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has four (4) bathrooms, of which three (3) are designated for residents' use, and one (1) is for staff use only. Bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids. The hot water delivered in the bathrooms measured at 10:50am to be at 113.8 degrees. Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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: J AND G SUNSHINE MANOR
FACILITY NUMBER: 197610533
VISIT DATE: 09/09/2024
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COMMON AREAS: These included living room and a dining room. The living room was equipped with furniture, a television, tables and chairs. There is no fireplace in the facility. The dining area has a dining room table to accommodate six (6) residents, buffet, a sofa and a piano. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 10:45am to be 68 degrees.

GARAGE: The garage is used as extra storage for non-perishable, emergency food supplies and water. There is another freezer/refrigerator in the garage for additional food items. LPA observed additional laundry detergents along with other chemicals are also stored in the garage.

LAUNDRY ROOM: The washer and dryer is located in a separate locked area next to the living room, laundry chemicals are also kept in the laundry area which is always locked and under supervision.

MEDICATIONS: The medications are kept locked in a cabinet located in the office area which is next to the kitchen. At approximately 12:00pm to 1:00pm LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. All medications are properly labeled and checked for expiration dates. First Aid and the new manual is also locked in the cabinet. LPA observed the First-aid has all proper items and is current.

Resident Files: From 11am to 12pm LPA conducted a file review of all client records to ensure compliance of licensing forms. Resident files are complete and kept locked in cabinet, in the hallway.
Staff Files: Staff files are also kept in a locked cabinet in the hallway area. From 1:00pm to 1:45pm LPA conducted staff file review, files were complete with all documents and training certificates.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) residents. There is no body of water.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised.

Exit interview conducted and copy of this report signed and delivered to the Administrator.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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