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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603763
Report Date: 08/28/2025
Date Signed: 08/28/2025 02:47:00 PM

Document Has Been Signed on 08/28/2025 02:47 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SUNSHINE RESIDENTIAL HOME 4FACILITY NUMBER:
198603763
ADMINISTRATOR/
DIRECTOR:		JOSE, OYINLOYE AUSTINEFACILITY TYPE:
735
ADDRESS:1053 S PROSPERO DRIVETELEPHONE:
(818) 274-1809
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 4CENSUS: 0DATE:
08/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Oyewole Jose, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA met with Administrator Oyewole Jose and explained the purpose of the visit.

The facility has an approved fire clearance to be licensed for four (4) non-ambulatory adults age range 18-59. Currently the licensee is awaiting vendorization from San Gabriel/Pomona Regional Center and the facility does not have any clients in care.

The single story home is located in a residential area of Glendora. The home consists of a kitchen, dining area, living room, 4 bedrooms, 2 bathrooms, laundry area, front and back yard.

LPA and licensee toured the physical plant interior and exterior. Inspection CARE Tool was used. The following was observed:

Laundry area observed in the hallway, washing machine and dryer were operable. Combination smoke and carbon monoxide detectors observed throughout the facility, were tested and are operable. The fire extinguisher located in the front hallway was observed to be charged.

continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SUNSHINE RESIDENTIAL HOME 4
FACILITY NUMBER: 198603763
VISIT DATE: 08/28/2025
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continued from 809

Kitchen was observed to be clean and free of pests. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Sharps will be secured, locked under the kitchen sink, inaccessible to clients. Medication will be centrally stored, secured in a locked filing cabinet located in the dining area, inaccessible to clients in care. Staff and client files will be maintained locked in a filing cabinet located in the dining area. The first-aid kit has required items, and a current manual was observed and is kept in the kitchen. Dining area was clean with sufficient seating. Living room was observed clean and free of obstructions with sufficient seating.

Grab bars and non-skid mats were observed in bathrooms. The water temperature was tested at 125 degrees F in both bathrooms and it is not within the required 105-120 degrees F. The licensee adjusted the water temperature at the time of visit. Licensee was issued a technical violation for water temperature.

Residents’ bedrooms have all require furniture which includes, for each resident, a bed, a chair, night stand, lights sufficient for reading. Bed linens were clean and in good repair. There is a closet with space for clothing and other belongings.

Doors, exits, hallways, and passageways were clear and free of obstruction. The front yard was observed to be clean and free of debris. The backyard had debris (old windows) that the licensee will dispose of. There is an outdoor shaded, seating area in a covered patio with sufficient seating for clients. No pools or bodies of water were observed in or around the home. There are no firearms present at the facility.

One staff file was reviewed and had the required documentation.

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 licensee.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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