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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601049
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:06:13 PM

Document Has Been Signed on 03/09/2023 04:06 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SUNGLOW HOMEFACILITY NUMBER:
198601049
ADMINISTRATOR:OBSTACULA, CRISTINAFACILITY TYPE:
735
ADDRESS:9734 SUNGLOW STREETTELEPHONE:
(562) 948-1681
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 4CENSUS: 3DATE:
03/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Cristina ObstaculaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Glenn Trueman made a visit to the facility and was greeted by Administrator Christina Obstacula and explained the reason for the visit.
The purpose of the visit is to conduct the required 2023 annual inspection.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environmental Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention.
Tour of the facility was conducted and the following was observed;
There are 2 Client Bedrooms which have the required furniture such as bedframes, dressers, lamps and chairs.
Beds have the required linen and the linen is in good condition.
There are 2 Client bathrooms. The bathrooms are clean and have the required hygiene items. The hot water temperature was within the required 105 - 120 degrees.
The facility temperature at the time the visit was comfortable.
There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility. There is a carbon monoxide detector. The kitchen was inspected. There is sufficient perishable and non-perishable food. The food was also stored properly. Kitchen appliances are clean and are operating properly. The front and backyard are well maintained. There is no pool or other large bodies of water.
Planned activities are conducted daily and there is sufficient space inside and outside of facility.
Staff and Client's were interviewed.
Deficiency cited 80087(a) on 809-D with Bedroom 2 Bathroom Screen ripped and Bedroom 1 blinds are broken.
Advisory Notices issued.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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Document Has Been Signed on 03/09/2023 04:06 PM - It Cannot Be Edited


Created By: Glenn Trueman On 03/09/2023 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SUNGLOW HOME

FACILITY NUMBER: 198601049

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above with Bedroom 2 Bathroom Screen ripped and Bedroom 1 blinds are broken. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2023
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
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