306003418-4-17-2024-22-AS-EKIM-D4F2L5-20240417172858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003418
Report Date: 04/17/2024
Date Signed: 04/17/2024 05:32:01 PM

Document Has Been Signed on 04/17/2024 05:32 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SUNSHINE HOME CARE		FACILITY NUMBER:	306003418
ADMINISTRATOR:	ESTER DELA CRUZ		FACILITY TYPE:	740
ADDRESS:	2428 WEST AVENUE		TELEPHONE:	(714) 525-1566
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	6	CENSUS: 5	DATE:	04/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ester Dela Cruz		TIME COMPLETED:	05:45 PM

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On April 17,2024 8:30am, Licensing Program Analyst (LPA) Edward Kim and Licensing Program Manager (LPM) Lourdes Montoya conducted an unannounced required 1-year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim and LPM Montoya met with Administrative (AD) Ester De La Cruz and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory residents and have a hospice waiver for 5 residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA Kim and LPM Montoya toured physical plant with AD De La Cruz. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Room 1, Room 2, Room 3, Room 4, and 1 Staff Bedroom. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 134 degrees F in Resident 3 bathroom, 132 degrees F in the common bathroom, and 137.6 degrees F in Resident 2 Bathroom. A comfortable temperature of 73 degrees F was maintained in the facility.

LPA Kim and LPM Montoya observed the facility to be sanitary and appropriately furnished. The Kitchen was inspected and there is sufficient supply of two (2) day perishable and seven (7) day non-perishable food available. The facility has operable smoke detectors and carbon monoxide. A working telephone (714-525-1566) remains available..

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE HOME CARE	FACILITY NUMBER: 306003418
	VISIT DATE: 04/17/2024

NARRATIVE

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During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Kim and LPM conducted an audit of residents #1-5 (R1-R5) service files, and staff #1-#2 (S1-S2) personnel files. One out of five resident's medical assessment is not current.

The following observations were made: fire extinguisher was not mounted and last serviced on 2/10/2023, facility has an outdoor make shift kitchen with refrigerator, kitchen cabinets filled with canned food and fruits and eggs on the counter, administrator's certificate expired on March 28, 2023, first aid kit was incomplete with missing tweezers, manual, gauze, medical tape, thermometer, and no activity was observed during the entire visit. Due to time constraints these deficiencies will be addressed on the continuation inspection on a later date; and staff/resident interviews and medication administration records review will be conducted on the next visit.

Deficiencies were cited during this inspection visit according to the 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 and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE HOME CARE	FACILITY NUMBER: 306003418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA Kim observed and measured the hot water temperature at 134 degrees F in Resident 4 bathroom, 132 degrees F in shared bathroom, and 137.6 degrees F in Resident 2 bathroom.This poses an immediate safety risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	Administrator agrees to the section cited above. The Licensee will adjust the water temperature and will create a temperature log for each bathroom and measure the temperature every two hours from April 17, 2024 5:00pm until April 18, 2024 5:00pm. Proof of correction of the above deficiencies will be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date April 18, 2024.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA Kim observed and took photos of a gallon of Clorox, kirkland laundry supply, and a bottle of Fabulouso cleaner in the laundry room, a bottle of lysol in resident 3 bathroom floor, and dishwasher liquid soap and other cleaning supplies unlocked under the kitchen sink. This poses an immediate safety risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	The administrator agreed to keep the above items inaccessible to residents. Proof correction of the above deficiencies will be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date April 18,2024.

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/17/2024 05:32 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE HOME CARE	FACILITY NUMBER: 306003418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed and took photos of the outdoor shed with broken panels which contain two hand saws and one shears.This poses an immediate safety risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	The administrator agreed to keep the above items inaccessible to residents. Proof correction of the above deficiencies will be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date April 18,2024

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/17/2024 05:32 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE HOME CARE	FACILITY NUMBER: 306003418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed and took photos of all four burner stoves were not operating, kitchen cabinet drawers above the stove do not close properly, the garage used for storage is not clean and organized, and wood scraps and glass panels outside of the garage, backyard, and back porch. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agreed to comply to this cited section. Proof of correction of the above deficiencies wil be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date, 4/26/2024.

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA Kim observed facility structure is not consistent with filed floor plan and clearance by having a Laundry room in a hallway and a bathroom in the garage. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit LIC200, application fee of $25, and updated Facility Sketch (floor plan) and will also submit proof of the building permits for garage alteration and hallway alteration. Proof of correction of the above deficiencies will be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date, 4/26/2024.

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/17/2024 05:32 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE HOME CARE	FACILITY NUMBER: 306003418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.319(a)

Regulations

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA Kim interviewed licensee about the facility not having an internet accessible device that residents can use. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provide an internet accessible device devoted for residents' use. Proof of correction of the above deficiencies will be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date, 4/26/2024.

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed and took photos of expired (on January 4, 2024)Pillsbury Turkey Sugar Cookie Dough, expired (on February 15, 2024) Elbow Macaroni box, and expired (February 15, 2024) blueberry muffin mix box.This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agreed to dispose expired food. Proof of correction of the above deficiencies will be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date, 4/26/2024.

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/17/2024 05:32 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE HOME CARE	FACILITY NUMBER: 306003418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observationand record review, the licensee did not comply with the section cited above in Residents with Special Health Needs - Type B: 87705(c)(5)(A) - R4's latest Physician Report is on 2/16/2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit a current Medical Assessment for R4. Proof of correction of the above deficiencies will be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date, 4/26/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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