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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003418
Report Date: 04/07/2022
Date Signed: 04/07/2022 04:15:28 PM


Document Has Been Signed on 04/07/2022 04:15 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SUNSHINE HOME CAREFACILITY NUMBER:
306003418
ADMINISTRATOR:ESTER DELA CRUZFACILITY TYPE:
740
ADDRESS:2428 WEST AVENUETELEPHONE:
(714) 525-1566
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 4DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ester DeLa CruzTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was granted entry into the facility by Administrator Ester DeLa Cruz and reason for the visit was explained. Administrator DeLa Cruz confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility.

LPA did not observe the required Department postings on COVID-19 precautions at entrance of facility and/or throughout the facility. There was a sign-in procedure in place and hand sanitizer for use. LPA observed staff were wearing face masks. The facility has an approved Mitigation Plan on file with CCLD. Four residents were present. One Resident is receiving Hospice care. LPA conducted a tour of the facility and made observations: LPA toured resident rooms, all rooms were within regulations. Restrooms observed contained hand washing soap, toilet paper and paper towels. The proper hand washing signs were missing but were placed during visit. Facility has operating smoke and carbon monoxide detectors. Facility's Fire Extinguisher was charged. LPA observed a copy of Administrators Certificate which expired on 03/28/2023. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted. Staff and Residents files and medication are locked in a hallway cabinet. Facility has 30 days supply of medications for the residents. Observations made by LPA based on Physical Plant will be addressed at a later date.

Based on observations made during today’s inspection focusing on Infection Control. no deficiencies will be cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report and LIC9102A with Administrators and a copy will be emailed.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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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