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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002996
Report Date: 07/16/2021
Date Signed: 07/16/2021 02:42:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SUNSHINE RETIREMENT HOMEFACILITY NUMBER:
306002996
ADMINISTRATOR:MARIETA MARQUEZFACILITY TYPE:
740
ADDRESS:17846 TACOMA CIRCLETELEPHONE:
(714) 532-6885
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY:6CENSUS: 5DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Marieta MarquezTIME COMPLETED:
10:05 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator Marieta Marquez and explained the reason for the visit. Care provider Stanley Soliven was present as well.

At 8:40 AM, LPA toured the facility with Administrator Marquez. Facility has 5 residents during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Hand washing signs are posted in the restrooms. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily. Facility has covid precaution postings as well as all required department postings. Marieta Marquez has an administrator certificate expiring on 10/30/2022. Facility has completed the mitigation plan and LPA approved the plan during the visit. LPA observed adequate emergency food and water supply as well as the first aid kit which contained all required items. Facility has all items of PPE on site. LPA toured the outside grounds and observed ample shaded outside visitation areas. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all resident files and all contained required documentation including updated emergency information.

LPA consulted with Administrator regarding the importance of documenting temperatures taken daily as well as having a back up staffing plan in the case of an emergency.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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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