<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603283
Report Date: 12/16/2024
Date Signed: 12/16/2024 11:57:26 AM

Document Has Been Signed on 12/16/2024 11:57 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VICTOR SUNSHINE RESIDENTIAL CAREFACILITY NUMBER:
198603283
ADMINISTRATOR/
DIRECTOR:		MORA, VICTOR OLIVER RFACILITY TYPE:
735
ADDRESS:1410 S. RIDLEY AVE.TELEPHONE:
(626) 346-3498
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 3DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator Victor Mora TIME VISIT/
INSPECTION COMPLETED:
12:05 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) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Victor Mora and the purpose of the visit was discussed. The following (CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan for LPA to review.
Operational Requirements:
  • A current Plan of Operation was reviewed.
  • A fire clearance for Four (4) clients of which (0) may be non ambulatory;0 may be bedridden.
Physical Plant/Environment Safety:
  • The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen, pantry, dining area, attached garage/office/storage, 4 bedrooms, 1 staff room, 2 and 1/2 bathrooms and laundry area
  • The physical plant was inspected. (1) Broken window was observed. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to clients. Fire Alarms were inspected. Fire extinguishers Observed
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.
Staffing
  • Sufficient staff observed to meet clients needs
  • Facility currently provides care and supervision for a total of Four (4) Clients.
Client Rights-Information
  • No postural Supports Observed
  • Internet source provided to clients in care


Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/16/2024 11:57 AM - It Cannot Be Edited


Created By: Jose Villalobos On 12/16/2024 at 11:22 AM
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: VICTOR SUNSHINE RESIDENTIAL CARE
FACILITY NUMBER: 198603283

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

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
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as there was a broken window observed in the living room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
Facility to repair broken window and to provide LPA with a picture of repair by POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 198603283
VISIT DATE: 12/16/2024
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
26
27
28
29
30
31
32
Personnel Records-Training:
  • Administrator on record current and Administrator Certification is active
  • Staff have criminal background clearance and training.
  • Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training was observed. Staff file have criminal record clearances and are associated.
Client Records-Incident Reports:
  • A total of Three (3) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.
  • Complaint poster and Personal rights were observed posted.
Health Related Services:
  • Two (2) Client centrally stored medications were reviewed. One (1) Client does not take medications
Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Sanitation practices and kitchen cleanliness was observed.
Incident Medical and Dental:
  • There are no clients in care with restricted or prohibited health conditions.
  • Individual Service Plans and Appraisals are on file.
Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610 is in place.
Emergency Intervention:
  • None used at this time


All (12) domains have been completed as of todays visit. Per California Code of Regulations, Title 22, a deficiency is being cited. Please see attached 809-D. Exit Interview was conducted. Appeal Rights were discussed. A copy of the appeal rights along with this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3