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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603283
Report Date: 01/21/2022
Date Signed: 01/24/2022 08:06:41 PM

Document Has Been Signed on 01/24/2022 08:06 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:VICTOR SUNSHINE RESIDENTIAL CAREFACILITY NUMBER:
198603283
ADMINISTRATOR:MORA, VICTOR OLIVER RFACILITY TYPE:
735
ADDRESS:1410 S. RIDLEY AVE.TELEPHONE:
(626) 346-3498
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 0DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Victor Mora TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual inspection. LPA met with administrator Victor Mora and explained the reason of the visit. LPA used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and was approved on 07/01/21.

Currently the facility has no client reside there. The facility is a one story house located at the residential neighborhood. The home consists of kitchen, living room, dining area, three clients' bedrooms, two and half bathrooms, staff bedroom, back pantry/storage room and a detached garage. The front and back yard are well maintained and the back yard has a shaded area and sitting area. The 1st bedroom has one bed, one closet, one dresser, required linen and furniture and sufficient lighting. The 2nd and 3rd bedroom has two beds, two dresser, required linen and furniture and sufficient closet space and lighting. All toilets, hand washing and bath tub/shower are safe, sanitary and in good operation condition. All sharp knifes and cleaning supplies were locked. LPA inspected the smoke detector and carbon monoxide and they are operable and in compliance. The hot water measured in the two bathrooms are between 118 and 120 degree F. LPA also observed food supply is adequate and probably stored. All the cleaning solution and toxic are stored and locked in the pantry. Due to no client currently reside in the facility, there's no medication to be reviewed during the annual inspection.

No deficiencies issued under California Code of Regulations of Regulations Title 22.

Exit interview conducted. A copy of the report was provided to Administrator Victor Mora.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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