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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340302290
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:27:59 PM

Document Has Been Signed on 03/16/2022 04:27 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNSHINE HOMEFACILITY NUMBER:
340302290
ADMINISTRATOR:HIMAT SINGHFACILITY TYPE:
735
ADDRESS:13445 MARENGO ROADTELEPHONE:
(209) 745-8566
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 15CENSUS: 14DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Himat Singh, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) T. White arrived to conduct an unannounced Required 1-Year Annual inspection on this date. LPA met with Administrator/Licensee, Himat Singh, and explained the purpose of the inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 15 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105.1 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

LPA observed smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on April 12, 2021. First aid kit was observed to be complete. Fire drill was conducted on 03/16/2022.
LPA observed the following deficiencies:
- LPA observed Staff #1 (S1) is not fingerprint cleared or associated to the facility. Licensee stated he received a letter from the Department of Justice (DOJ) regarding S1's clearance. However, there is no proof S1 is cleared in CCLD database.

The following forms to be updated and submitted to CCLD by 03/25/2022:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610E Emergency Disaster Plan

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Administrator/Licensee. A copy of report and Appeal Rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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Document Has Been Signed on 03/16/2022 04:27 PM - It Cannot Be Edited


Created By: Treana White On 03/16/2022 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNSHINE HOME
FACILITY NUMBER: 340302290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documentation and LPA observation, the licensee did not comply with the section cited above in 80019(e)(1) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2022
Plan of Correction
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Administrator removed Staff #1 (S1) from the facility. Administrator agreed to have S1 fingerprinted and associated to the facility. Administrator agreed to submit proof to CCLD by POC date.
CIVIL PENALTY ASSESSED - 500.00
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


LIC809 (FAS) - (06/04)
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