198320337-11-17-2023-11-AS-LMOA-CXNV9V-20231117151458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320337
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:15:08 PM

Document Has Been Signed on 11/17/2023 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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: 5	DATE:	11/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:11 AM
MET WITH:	RUSTICO PUNSALAN/RUBY PUNSALAN		TIME COMPLETED:	03:20 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 11/17/2023 at 11:11 AM, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Caregivers Vanessa Vidanes and Edson Vidanes. LPA explained the purpose of today’s visit. Administrator/Licensee Rustico Punzalan and Licensee Ruby Punzalan arrived later and joined the visit. The facility is licensed to operate for six (6) residents ages range 60, six (6) non-ambulatory of which one (1) may be bedridden, hospice waiver for six (6). Currently, there are five residents. Three out of five residents are non-ambulatory, no bedridden and no hospice residents. 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. At around 11:15 AM, LPA toured the physical plant with Caregiver Vanessa Vidanes. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 112.1 degrees F. A comfortable temperature of 76 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place. (Evaluation Report continues LIC 809-C)

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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 HARBOR LLC	FACILITY NUMBER: 198320337
	VISIT DATE: 11/17/2023

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and 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.

LPA observed First Aid Kit was maintained. A working landline phone (424-378-1145) is operational. The last fire drill was conducted on 10/10/2023. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 7/12/23-7/12/24. The facility is current on Community Care Licensing annual dues.

An audit of resident #1-#5 (R1-R5) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete.

Interviews were conducted with two residents and two staff. The facility has the current administrator's certification #6062032740 with expiration date of 1/14/2024.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed deficiency and issued a citation, deficiency is on the LIC 809D.

An exit interview was conducted with Administrator Rustico Punzalan, and a copy of the report was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/17/2023 03:15 PM - It Cannot Be Edited

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 HARBOR LLC	FACILITY NUMBER: 198320337
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(6)

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights. (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents,or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. On 11/17/2023 at 11:30 AM, LPA Montoya observed the right side gate was locked. S1 stated the gate is usually locked at night. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure the gate is always unlocked. Administrator shall remove the locking mechanism of the gate latch. POC shall be submitted to CCLD via email to lourdes.montoya@dss.cagov by the POC due date 12/1/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC809 (FAS) - (06/04)

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