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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603294
Report Date: 04/12/2023
Date Signed: 04/12/2023 09:36:24 AM

Document Has Been Signed on 04/12/2023 09:36 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SUNSHINE ASSISTED LIVINGFACILITY NUMBER:
198603294
ADMINISTRATOR:MARY MONTIANOFACILITY TYPE:
735
ADDRESS:3141 EUCLID AVETELEPHONE:
(310) 638-3847
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 68CENSUS: 65DATE:
04/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Mary Montiano-AdministratorTIME COMPLETED:
09:20 AM
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On 4/12/2023 Licensing Program Analyst, LPA Alfonso Iniguez conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by Mary Montiano/Administrator and explained the purpose of the visit was to gather information surrounding the death of (C1).

The regional office received a copy of the death report from the facility and reported the death of (C1) on 4/10/2023. The death report stated that on 4/7/2023 (C1) was found by staff #1 (S1) on the floor unresponsive and unconscious. Staff #1 called 911 emergency. Paramedics came and checked C1 pulse and pronounced C1 dead.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. Resident rooms were inspected, beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed.

A copy of the following documents was provided to LPA:
*C1 chart
* C1 MAR
* Personnel Roster


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Administrator/Mary Montiano.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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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