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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003558
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:04:09 AM

Document Has Been Signed on 03/19/2024 11:04 AM - 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:SUNBEAM BARRIOS HOMEFACILITY NUMBER:
347003558
ADMINISTRATOR:BARRIOS, NORMANFACILITY TYPE:
735
ADDRESS:8579 PHEASANT HILL CTTELEPHONE:
(916) 988-5248
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 6DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Staff (DSP)-Thelma MamarilTIME COMPLETED:
11:15 AM
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On 03/19/24, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct a required annual inspection. LPA met with Staff (DSP)-Thelma Mamaril (S1) and explained purpose of inspection. The facility is an ARF that is vendorized through Alta California Regional Center. There are (6) clients who reside at the home.

LPA and S1 toured the interior and exterior of the facility including the common areas, client bedrooms, client bathrooms, kitchen, laundry area/garage. LPA observed the home to be clean, safe and in good repair. Inside temperature was observed to be 70* F. Fire extinguisher last serviced 02/06/24 and was ready for emergency use. Facility conducts monthly fire and disaster drills, at different hours of the day. The facility has a large back yard area with seating. There are no pools/ponds. LPA observed locked toxins in the laundry area and locked medications in a separate cabinet. LPA observed sufficient 2+day perishable/7+day non-perishable food and sufficient PPE on hand. LPA observed paper towels, soap, sanitizer, trash cans and hand-washing posters in the bathrooms. Smoke/monoxide alarms were in working order. Games/activities observed on site.

LPA reviewed (3) client files and (2) staff files and found the required documentation on file, including staff training. LPA reviewed medications for (3) clients and found out that facility was using Centrally Stored Log and MAR Records for medications management without any issues.

LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 04/05/24.

Deficiencies were observed and cited today per Title 22 ,Regulations as indicated on 809-D.
Exit interview conducted. A copy of this report and appeal rights were printed and given to staff, S1.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 03/19/2024 11:04 AM - It Cannot Be Edited


Created By: Talwinder Bains On 03/19/2024 at 10:48 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNBEAM BARRIOS HOME
FACILITY NUMBER: 347003558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations ,LPA observed knives ,sharp objects in kitchen area and scissor in resident ,R1s drawer accessible to residents during inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2024
Plan of Correction
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Licensee/Administrator shall send a letter of understanding of this regulation and will do staff training regarding this issue. POC documents are required by POC date-03/20/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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