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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320165
Report Date: 05/05/2024
Date Signed: 05/05/2024 04:21:50 PM


Document Has Been Signed on 05/05/2024 04:21 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:SUNSHINE BOARD AND CAREFACILITY NUMBER:
198320165
ADMINISTRATOR:MABUTAS, RHODAFACILITY TYPE:
740
ADDRESS:2070 250TH STREETTELEPHONE:
(424) 328-0126
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 6DATE:
05/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:MABUTAS RHODATIME COMPLETED:
04:40 PM
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On 05/05/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by Administrator Rhoda Mabutas and explained the purpose of today’s visit. Later joined with Ruby Ana Punzalan. 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, laundry area, and outside shaded patio area. There is an attached garage used for storage only. The garage contains an additional pantry for food storage and the freezer for food.

LPA conducted a records review of staff record, and resident records and Medication Administration Record, LPA did not observe any discrepancies at the time of visit. 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. Bathrooms were found to be within Title 22 regulations and were operational.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SUNSHINE BOARD AND CARE
FACILITY NUMBER: 198320165
VISIT DATE: 05/05/2024
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The hot water temperature measured between 114.5F to 113.5F degrees. in all bathrooms and kitchen sink. A comfortable temperature was maintained in the facility.

The kitchen was inspected and there is sufficient perishable and non-perishable food available properly maintained. LPA observed the facility to be appropriately furnished at the time of visit. LPA observed cleaning supplies and toxins in locked cabinets. Three (3) fire extinguishers were charged with one in the living room, kitchen area and hallway, smoke detectors and carbon monoxide were operable. The last fire drill conducted on 03/29/2024. There was a first aid kit available located in the living room.


During today’s visit no discrepancies were cited. Exit interview conducted with Administrator Rhoda Mabutas, and a copy of this report was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2024
LIC809 (FAS) - (06/04)
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