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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603333
Report Date: 07/06/2022
Date Signed: 07/06/2022 10:34:43 AM

Document Has Been Signed on 07/06/2022 10:34 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:SUNSHINE COTTAGEFACILITY NUMBER:
198603333
ADMINISTRATOR:RESURRECCION, FLORMINEFACILITY TYPE:
735
ADDRESS:4550 BELLFLOWER BLVDTELEPHONE:
(562) 572-9931
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 4DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Assistant administrator, Maria Tavarez TIME COMPLETED:
10:49 AM
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Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Assistant Administrator, Maria Tavarez who assisted with the visit.

The facility is licensed to serve 4 clients between the age of 18 and 59 years old. Approved for 4 non ambulatory, of which 2 shall be bedridden. Approved hospice waiver for 2. The facility is a single-story building in a residential area, with a sitting room, kitchen, dining room, Living room with covered fireplace, 4 bedrooms, 2 bathrooms, detached garage, and a backyard. The carbon monoxide/ smoke detectors were observed and tested in working condition. Fire extinguisher observed on the kitchen wall.

LPA discussed infection control practices with assistant administrator and care giver, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

LPA observed all bedrooms with the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The backyard is well maintained with shaded area. The bathrooms are clean, and showers have non-skid materials and grab bars. The hot water temperature measured between 111.6- 114.6 degrees F. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. All sharps are locked and secured. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. Medications reviewed for all residents and appears to be given as prescribed. Staff file review was complete and have the required background and health screening. Infection control signs posted throughout the facility and LPA observed 30 days’ supply of PPE’s located in the sitting room. Last disaster drill conducted May 18th, 2022. Administrator certificate # 6000617735 expire 7/8/2023.

Report continued on 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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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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: SUNSHINE COTTAGE
FACILITY NUMBER: 198603333
VISIT DATE: 07/06/2022
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Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to assistant administrator, Maria Tavarez
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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