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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 03:25:10 PM

Document Has Been Signed on 03/16/2022 03:25 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Himat Singh, LicenseeTIME COMPLETED:
03:40 PM
NARRATIVE
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On 03/16/2022 at 2:45pm, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a case management visit. LPA met with Administrator/Licensee, Himat Singh and explained the purpose of the visit.

Based on documentation, the facility had COVID positive clients in January 2022. On 01/24/2022, LPA Jacobs confirmed with Licensee there are no new positive cases. Based on Licensee interview, staff and clients completed only one round of response testing. The facility did not conduct two (2) consecutive rounds of response testing.

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. 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 03:25 PM - It Cannot Be Edited


Created By: Treana White On 03/16/2022 at 02:44 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2022
Section Cited
CCR
1550(c)

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1550(c): Licenses or administrator certificate:(c)Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.
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Licensee agreed to conduct in-service training with all staff and submit proof to CCLD by POC date. Licensee agreed to conduct testing for all staff and residents by 03/23/2022 and submit proof to CCLD.
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Based on observation and interview, facility did not comply with the section 1550(c). LPA observed facility did not conduct 2 rounds of testing, which is a potential health and safety risk to clients.
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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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