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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002996
Report Date: 08/19/2024
Date Signed: 08/19/2024 10:53:53 AM


Document Has Been Signed on 08/19/2024 10:53 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, 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: 3DATE:
08/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Marieta MarquezTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 07/31/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Deficiency cited under Health and Safety Code 1569.605 pertaining to Liability Insurance has been cleared. Licensee provided proof of insurance. Licensee has complied with the POC.

Deficiency cited under Health and Safety Code 1569.695(c) pertaining to Emergency Drills has been cleared. Licensee provided proof of emergency drill. Licensee has complied with the POC.

Deficiency cited under Title 22 Regulation 87608(a)(3) pertaining to Postural Supports has been cleared. Licensee provided proof of physician orders for bed rails. Licensee has complied with the POC.


During today's visit, Licensee has ample emergency water.




Exit interview 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: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
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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