<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002867
Report Date: 06/22/2023
Date Signed: 06/22/2023 12:12:40 PM


Document Has Been Signed on 06/22/2023 12:12 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SUNSHINE CARE HOMEFACILITY NUMBER:
345002867
ADMINISTRATOR:CRISAN, ADELAFACILITY TYPE:
740
ADDRESS:5010 OLEAN STREETTELEPHONE:
(916) 966-6042
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Denisa Crisan, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Denisa Crisan, to follow-up on a plan of correction made to the facility on 5/23/2023 to be corrected on 6/16/2023.

During today's visit, LPA took the temperature of the tap water from four faucets. Faucet in one shared bathroom got to 110 degrees F before dropping in temperature. Faucet in resident (R1's) personal bathroom got up to 107 degrees F before dropping in temperature. Faucet in kitchen got to 122 degrees F before dropping in temperature. Faucet in resident (R2's) personal bathroom got up to 124.9 degrees F.

As a result of this visit, deficiency was observed to not be corrected and a civil penalty in the amount of $600 was assessed because the facility did not comply with a plan of correction for the time period of 5/23/2023 thru 6/16/2023.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1