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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603333
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:00:03 PM

Document Has Been Signed on 08/03/2023 03:00 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SUNSHINE COTTAGEFACILITY NUMBER:
198603333
ADMINISTRATOR:MARIE JHOANNA RESURRECIONFACILITY TYPE:
735
ADDRESS:4550 BELLFLOWER BLVDTELEPHONE:
(562) 572-9931
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 4DATE:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Marie Resurreccion - AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Marie Resurreccion (Administrator) and explained the reason for the visit. The facility is licensed to serve 4 non-ambulatory clients in the age range of 18 through 59, of which 2 may be bedridden. Facility is approved for 2 hospice waiver. The facility is operating within the scope of its license.

A tour of the single-story facility included the waiting area, living room, dining area, kitchen, laundry area, 4 client bedrooms, 2 client bathrooms, front yard, backyard, and detached garage. During the tour the following was observed: the front porch and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in both bathrooms and measured at 107.7 degrees F and 105.4 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Client beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a hallway closet. Smoke detectors combined with carbon monoxide were observed in each room and throughout the facility, and were properly operating. There is one fire extinguisher located in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked under the kitchen sink and are inaccessible to residents. Cleaning supplies and toxins are kept locked in the laundry area and are inaccessible to residents. Fireplace has a cover. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept locked in the medication closet. Residents and staff files are centrally stored in the medication closet. Residents medication are centrally stored in a dining area closet.

LPA reviewed medication for 3 clients and observed that medications are documented properly and given as prescribed. One of the clients is on vacation with family and took the medication. LPA reviewed files for all 4 clients and 5 staff. LPA observed the administrator certificate for Marie Resurreccion - 6064058735 with an expiration date of 06/24/2024. LPA reviewed P&I funds for all 4 residents with staff present. LPA interviewed 2 staff. Clients were unavailable or not at the facility to interview. Facility has a valid surety bond .
(Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SUNSHINE COTTAGE
FACILITY NUMBER: 198603333
VISIT DATE: 08/03/2023
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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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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