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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318075
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:05:13 PM

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 GLORY CARE HOMEFACILITY NUMBER:
340318075
ADMINISTRATOR:AGUDA, MERLYFACILITY TYPE:
740
ADDRESS:9845 ALTA MESA ROADTELEPHONE:
(916) 687-7874
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY:12CENSUS: 11DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Merly AgudaTIME COMPLETED:
12:15 PM
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On 08/18/21 at 10:00 AM, Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio introduced herself, met with Administrator Merly Aguda, and explained the purpose of the visit. Additionally, LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility.

LPA Valerio inspected the physical plant including but not limited to the kitchen, dining room, resident bedroom, resident bathroom, laundry room/storage room, living room, staff bedroom, and outside areas of the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility has an LIC 808 mitigation plan on file. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. The facility is able to host indoor and outdoor visits. LPA observed the facility to have COVID-19 informational signs at the front door. The facility is able to designated and dedicated a Covid-19 bedroom and bathroom if needed. Administrator has implemented cleaning of common areas after each use. LPA Valerio recommended facility to create a PPE bin and to print out additional CDC guidelines for Donning and Doffing.

Water temperature reads 111.2° F, within regulatory range of 105*F and 120 *F. Room temperature reads 77° F. Smoke and carbon detectors were in good repair. Fire extinguishers was up to date with last check on 04/09/2021. Medications cabinet and cleaning supplies was locked. LPA Valerio smelled an odor in the front area of the home. LPA observed staff cleaning of the vent, floors, and common areas at the time of visit.

LPA obtained updated facility documentation: LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Liability Insurance, and Microbiological Water Analysis.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a copy of the report was given to Administrator Merly Aguda.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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