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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004080
Report Date:
05/04/2022
Date Signed:
05/04/2022 03:11:51 PM
Document Has Been Signed on
05/04/2022 03:11 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 CARE HOME
FACILITY NUMBER:
306004080
ADMINISTRATOR:
SHELLY/MICHAEL MARTINEZ
FACILITY TYPE:
735
ADDRESS:
536 HANOVER STREET
TELEPHONE:
(714) 828-5008
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
6
CENSUS:
5
DATE:
05/04/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Shelly Martinez, Michael Martinez
TIME COMPLETED:
03:28 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA met with Administrator Shelly Martinez and explained the reason for the visit. Administrator Michael Martinez was also present. LPA toured the facility with the Administrator. Facility is a single story house with an attached garage which is used for storage of food and supplies. Facility has 4 bedrooms and 2 bathrooms. One bedroom is for staff. Facility is clean and organized. All residents rooms had the required elements and were clean. Restrooms were clean and operational. Facility smoke detectors and carbon monoxide detectors are operational. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station next to the facility entrance. Facility utilizes a visitor sign in sheet. LPA observed Covid-19 precautionary postings as well as all required department postings. Shelly Martinez has an administrator certificate expiring on 01/14/2023. Facility has completed the mitigation plan and LPA observed the emergency disaster plan posted in facility as well. LPA observed adequate emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed a covered patio and seating area. Exit gates are both operational. No bodies of water observed. LPA did not observe any hazards or obstructions in the backyard. LPA observed the locked medication storage area. Facility has a 30 day supply of PPE. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. The kitchen is clean and organized. No deficiencies observed during today's visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/04/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/04/2022
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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