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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003418
Report Date: 06/16/2022
Date Signed: 06/16/2022 04:02:24 PM


Document Has Been Signed on 06/16/2022 04:02 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: 5DATE:
06/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:51 PM
MET WITH:Ester DeLa CruzTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Case Management - Annual Continuation. LPA Martinez met with Administrator (AD) Ester DeLa Cruz and stated the purpose of this visit.

During the 04/07/2022, Facility's Required-1 Year inspection visit, LPA toured the interior and exterior portions of the facility with AD DeLa Cruz. During the walk through the following deficiencies were observed and verified with AD DeLa Cruz:
  • Garage is converted into a live-in space (staff room) with a storage room and a full bathroom;
  • a make shift kitchen with refrigerator, kitchen cabinets, operating gas range, and dining table is set up outside under covered patio.
  • broken dressers, old bikes, wood scraps, and plastic bins, were observed around the house, side of garage and under the house patio;
  • food in pantry was expired (Hungry Jack powdered smashed potato expired 7/2021; Pretzels expired 7/2021; Chocolate chip cookies expired 1/21/2022; Balsamic expired 12/2021;
  • Hallway freezer was observed with freezer burned vegetable bags and freezer burned meat.

Based on the observations made during the visit on 4/7/2022, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with AD DeLa Cruz and a copy of this report, LIC809D, and Appeal Rights will be emailed.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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


Document Has Been Signed on 06/16/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 306003418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited

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Alterations to Existing Building or New Facilities(a) Prior to construction or alterations, all facilities shall obtain a building permit. (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement is not met as evidenced by:
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Based on observation, facility did not comply with regulation cited above. LPA observed facility structure is not consistent with filed floor plan and fire clearance. This poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/16/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 306003418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited

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Maintenance and Operation -(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by: LPA observed broken dressers, old bikes, wood scraps, and plastic bins, around the house, side of garage and under the house patio. This poses a potential health and safety risk to residents in care.
Type B
06/23/2022
Section Cited

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General Food Requirements (8) All food shall be of good quality...Food in damaged containers shall not be accepted, used or retained... This requirement is not met as evidenced by: LPA observed expired food in pantry (Hungry Jack powdered smashed potato expired 7/2021; Pretzels expired
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7/2021; Chocolate chip cookies expired 1/21/2022; Balsamic expired 12/2021;
Hallway freezer was observed with freezer burned vegetable bags and freezer burned meat. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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