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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003835
Report Date: 07/27/2022
Date Signed: 07/27/2022 11:05:07 AM

Document Has Been Signed on 07/27/2022 11:05 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNSHINE HEALTHCARE INC.FACILITY NUMBER:
347003835
ADMINISTRATOR:KIBREAB, YESHIFACILITY TYPE:
735
ADDRESS:6624 GALLOWAY WAYTELEPHONE:
(916) 647-3024
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Yeshi Kibreab - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA explained purpose of visit to staff, who was requested by LPA to contact the facility Administrator, who arrived shortly thereafter.

Current census was 4 residents and residents were attending their respectable day programs.
Tour of the facility was conducted. Common areas were toured. Living area, recreation area, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were in good repair and able to meet the needs of the residents at this time.
Kitchen area was toured. Cabinets and drawers were opened and the contents were reviewed to make sure that there was an ample supply of cups, dishes, and all other items able to meet the needs of the residents at this time. Food supply was reviewed for adequate 2 day perishable and 7 day nonperishable food quantities.

First aid kit was reviewed and observed to contain all required components at this time.
Fire extinguisher was observed to have been annually inspected by the local fire extinguisher company, Fire Code, on 03/18/2022 and observed to be in compliance at this time. A tour of the resident bedrooms and restrooms was conducted. Resident bedroom furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time.

Hot water temperatures was measured in kitchen sink to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees.

Continued on 809-C
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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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 HEALTHCARE INC.
FACILITY NUMBER: 347003835
VISIT DATE: 07/27/2022
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Continued from 809 - Page 2


Laundry area was toured. It was observed that laundry detergents, cleaners, and cleaning supplies were locked and made inaccessible to the residents at this time.
Garage area was toured. Additional food storage units were observed to be present and reviewed by this LPA. Storage cabinets were opened by the facility designated Administrator and reviewed.

A review of the medications for the residents, stored in a kitchen cabinet, was conducted. A review of the facility Medication Administration Record, dispensing log, and Control Book for narcotics was conducted.
Linen closet was reviewed and observed to contain a sufficient supply of sheets, blankets, and covers in order to properly meet the needs of the residents at this time.
Exterior grounds of this facility was toured. A review was conducted in regards to the facility perimeter fence and side gates.
A review of (3) facility personnel records was conducted.
A review of (4) facility resident records was conducted.

This LPA requested that the following forms be updated and were received on today's date:
LIC 308 & LIC 610D.

There were no deficiencies observed or cited during todays' annual visit.

Exit Interview conducted with administrator and copy of report left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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