198320337-11-9-2022-11-AS-LMOA-CKZLHU-20221109074656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320337
Report Date: 11/08/2022
Date Signed: 11/09/2022 07:47:12 AM

Document Has Been Signed on 11/09/2022 07:47 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUNSHINE BOARD AND CARE HARBOR LLC		FACILITY NUMBER:	198320337
ADMINISTRATOR:	PUNZALAN, RUSTICO		FACILITY TYPE:	740
ADDRESS:	23411 HALLDALE AVE		TELEPHONE:	(424) 378-1145
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 0	DATE:	11/08/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	RUSTICO PUNZALAN		TIME COMPLETED:	03:15 PM

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On 11/8/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced visit to this home. LPA was greeted by Applicant Rustico Punzalan and explained the purpose of today’s pre-licensing inspection visit.

An application was submitted to CCLD on 8/30/2022 for an Initial Application for a Residential Facility for the Elderly. The applicant requested a capacity of five (5) non-ambulatory and one (1) bedridden individuals.

LPA Montoya toured the indoor and outdoor of the physical plant with Applicant Punzalan.

Structure:
The facility is a one-story house located in a residential neighborhood and consists of four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms and a two car garage. The home also consists of a living room, dining room, and kitchen. The facility is clean, sanitary, and in good repair. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees Fahrenheit. Fireplaces and open-faced heaters are inaccessible to clients.

Bedrooms (Residents):

All bedrooms include (1) a bed, one (1) chair, one (1) nightstand, one (1) table lamp. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath, or toilet.

Bedrooms (Staff):

There is one (1) staff bedroom.

Bathrooms:
The home has one (1) common bathroom and one (1) ensuite bathroom. All resident bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Evaluation Report Continues

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNSHINE BOARD AND CARE HARBOR LLC	FACILITY NUMBER: 198320337
	VISIT DATE: 11/08/2022

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Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet adjacent to the client’s bedrooms and bathroom.

Emergency Phone Numbers, Exit Plan & Menu:
The exit plan and menu are posted and readily available for review throughout the home. There are three (3) mounted fire extinguishers. A telephone line (424) 378-1145 is available in the kitchen. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant’s Mitigation Plan was approved on 10/20/2022.

Food Service:
All kitchen areas are clean and free of litter, rodents, vermin, and insects. The refrigerator and freezer are clean and of adequate size. The freezer is maintained at 0 degrees Fahrenheit and the refrigerator is below the required maximum of 40 degrees Fahrenheit. A two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food were observed. All equipment, appliances, dishes, and utensils are clean and well maintained.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are operable.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet and in the garage.

Water Temperature:
The water temperature is 116.7 degree Fahrenheit.

REPORT CONTINUED IN LIC809C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNSHINE BOARD AND CARE HARBOR LLC	FACILITY NUMBER: 198320337
	VISIT DATE: 11/08/2022

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Medications, First-Aid Kit & Book:
A first aid kit is stored in a locked cabinet which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to clients. The client's medications are stored in a locked cabinet in the dining area.

Clients & Staff Files:
The applicant is not handling the cash resources of the residents. Records of staff and residents are stored in a locked cabinet in the dining area.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the client's use all stored in the activity room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Fire clearance:
A Fire Clearance inspection was conducted on 9/14/2022 with approval for a capacity of five (5) non-ambulatory and one (1) bedridden.

Component III:
Component III was completed by the Applicant at the Pre-Licensing inspection on Tuesday, 11/8/2022. Information provided about how to operate the facility within substantial compliance. When the applicant/administrator was asked if he understood Title 22, he responded in the affirmative.

An exit interview was conducted, and a copy of this report has been furnished to the Applicant Rustico Punzalan. LPA Montoya will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

END OF REPORT

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC809 (FAS) - (06/04)

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