198320165-4-18-2022-11-AS-DSEA-CDM2ZG-20220418175018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320165
Report Date: 04/18/2022
Date Signed: 04/18/2022 05:50:30 PM

Document Has Been Signed on 04/18/2022 05:50 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUNSHINE BOARD AND CARE		FACILITY NUMBER:	198320165
ADMINISTRATOR:	MABUTAS, RHODA		FACILITY TYPE:	740
ADDRESS:	2070 250TH STREET		TELEPHONE:	(424) 328-0126
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	6	CENSUS: 6	DATE:	04/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Rhoda Mabutas - Administrator		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/18/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by Administrator Rhoda Mabutas and explained the purpose of today’s visit. The facility is licensed to serve six (6) non-ambulatory elderly residents ages 60 and above of which one (1) can be bedridden in room #3 and two (2) can be on hospice care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, three (3) bathrooms, living area, dining area, kitchen, and outside shaded patio area. LPA and Administrator Rhoda Mabutas toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured between 112.0 F to 119.8 in all bathrooms and kitchen sink. A comfortable temperature was maintained in the facility. There is an attached garage used for storage only. The garage contains an additional pantry for food storage and the freezer for food. The washer and dryer are located near the kitchen area. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNSHINE BOARD AND CARE	FACILITY NUMBER: 198320165
	VISIT DATE: 04/18/2022

NARRATIVE

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LPA observed the facility to be appropriately furnished at the time of visit. LPA observed cleaning supplies and toxins in locked cabinets. The kitchen was inspected and there is sufficient perishable and non-perishable food available properly maintained. The facility does their grocery shopping at least once a week or as needed. Two (2) fire extinguishers were charged with one in the kitchen area and hallway, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate. There was a first aid kit available located in the living room.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

Advisory Notes – Two (2) Technical Assistance were issued, please see LIC9102-AN.

Three were no deficiencies cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Rhoda Mabutas.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC809 (FAS) - (06/04)

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