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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318075
Report Date: 02/03/2022
Date Signed: 02/03/2022 02:03:45 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:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Merly AgudaTIME COMPLETED:
01:34 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct the annual inspection. LPA Valerio confirm with Administrator that zero residents or staff have displayed signs or symptoms of COVID in the last 10 days. LPA was screened by Administrator prior to being allowed entry into the facility.

LPA Valerio completed the infection domain tool, discussed PIN 21-53 and PIN 22-04, and reviewed facility COVID tracking procedures. Facility staff are said to clean multiple times per shift. COVID-19 signs regarding social distancing, hand washing, infection control, and prevention strategies are placed at the front area of the home. Visitors are encouraged to meet outdoors on the front patio.

LPA Valerio and staff toured the physical plant interior and exterior to ensure compliance with Title 22 regulations. All emergency exits were clear from obstructions. A two-day supply of perishable foods and a seven-day supply of non-perishable foods were observed in the refrigerators and freezers. An emergency supply of food and water was observed. Medication cabinet, cleaning supplies, and sharps were locked away and inaccessible to residents in care. Hot water was measured at 117.1*F. Room temperature was set to 74*F. All required furniture and furnishings were observed in the resident bedrooms and bathrooms. Fire extinguishers were observed to be charged and within compliance with last check on 04/08/2021. LPA Valerio was made aware of future carpet changes in the hallway, which is said to be completed by April 2022.

LPA reviewed facility documentation binder and discussed emergency disaster plan with Administrator Merly. LPA requested facility documentation to be sent via fax by COB 02/10/2022: Administrator Certificate, LIC 610, LIC 308, LIC 500, LIC 309, Liability Insurance.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administrator Merly Aguda.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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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