198602591-11-4-2025-11-AS-BBAI-DN4TCP-20251104133706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602591
Report Date: 11/04/2025
Date Signed: 11/04/2025 01:37:54 PM

Document Has Been Signed on 11/04/2025 01:37 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,
, CA

FACILITY NAME:	SUNSHINE RESIDENTIAL HOME 5		FACILITY NUMBER:	198602591
ADMINISTRATOR/ DIRECTOR:	JOSE, OYNLOYE AUSTINE		FACILITY TYPE:	735
ADDRESS:	8933 ORCHARD AVENUE		TELEPHONE:	(818) 274-1809
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90044
CAPACITY: 4		CENSUS: 2	DATE:	11/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:14 AM
MET WITH:	Precious Brown		TIME VISIT/ INSPECTION COMPLETED:	01:50 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	Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, LPA met with staff and explained the reason for the visit. House Manager Precious Brown arrived shortly after. Facility is a single-story residence that consists of four (4) client bedrooms. The facility is vendored through South Central Los Angeles Regional Center. The Facility does handle cash resources for all clients. Surety Bond is current. At approx 11:20 a.m., LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. (1) client was in the hospital during the visit. The LPA inspected the kitchen/food service area. Kitchen appliances appeared clean and to be in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharp objects were observed locked and inaccessible underneath the sink. LPA observed four (4) client bedrooms , which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The client bathrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit. At the time of the visit, the common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in cabinet in the kitchen. The facility maintained a comfortable temperature of 71 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers throughout to be fully charged and purchased in April of 2025. There is an office area located next to dining area. LPA observed board games, books and other activities stored in various locations inside the home.

NAME OF LICENSING PROGRAM MANAGER: Alex Estrada
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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,
, CA

FACILITY NAME: SUNSHINE RESIDENTIAL HOME 5	FACILITY NUMBER: 198602591
	VISIT DATE: 11/04/2025

NARRATIVE

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There is a laundry area located next to the kitchen. LPA observed it to be inaccessible to clients in care. LPA observed extra cleaning supplies, napkins, PPE, Emergency food supply, and emergency water. Client medication and facility documents are kept in this area as well. The backyard has a covered area equipped with furniture including a table and chairs for client use. The LPA observed clear passageways clear of obstruction. The LPA observed required postings throughout the common areas.

Records review, two (2) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time . Last emergency disaster drill was conducted on 09/25/2025.

Medications review, all medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

LPA obtained the following documents at the time of visit: LIC500 Personnel Report and LIC9020 Client Roster. Interviews conducted during the visit.

Exit interview conducted. A copy of the report was provided

NAME OF LICENSING PROGRAM MANAGER: Alex Estrada
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

LIC809 (FAS) - (06/04)

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