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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318075
Report Date: 11/30/2021
Date Signed: 11/30/2021 04:44:46 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: 10DATE:
11/30/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:47 PM
MET WITH:Merly AgudaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a case management visit due to the regional office receiving notification that the facility has bed bugs and that a resident received an eviction notice. LPA Valerio attempted to contact the facility, however, the line was busy. LPA Valerio was met at the front door by Administrator Merly. Administrator confirmed zero residents and staff have displayed any signs or symptoms of COVID-19 in the last 10 days. LPA Valerio was screened for COVID-19 symptoms prior to being allowed entry.

Administrator Merly stated there are currently 10 residents. Zero residents have been given an eviction notice. Administrator stated there is not bed bugs at the facility. The facility is serviced for pest from Ambush Pest Control. A telephone interview was conducted with Ambush Pest Control Representative and Administrator Merly. Ambush Pest Control Representative stated that there has not bed bugs in the facility for a few years. The representative comes once a month to service the inside of the home and outside of the home. LPA obtained most recent copy of service. LPA to receive a letter from Ambush to confirm that there is no current bed bugs in the facility.

LPA inspected the facility. There was an odor in the front of the home. LPA Valerio advised that the licensee obtain air freshener for the home. LPA observed that the knives were kept in am unlocked cabinet instead of the locked cabinet, which poses a potential health and safety risk to residents and staff.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during this visit and can be found on LIC 809-D. An 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: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 340318075
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited

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87309Storage 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.(1) ...other dangerous weapons shall be locked. This requiement was not met as evidenced by:
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Based on observation, the licensee did not ensure that sharps were locked and inaccessible to clients, which poses a potential health and safety risk to persons in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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