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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880681
Report Date: 08/08/2023
Date Signed: 08/08/2023 12:01:54 PM


Document Has Been Signed on 08/08/2023 12:01 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SUNSHINE BOARD & CAREFACILITY NUMBER:
361880681
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:720 N LINDEN AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:12CENSUS: 10DATE:
08/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Yusef Nofal, AdministratorTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) conducted an unannounced complaint visit for complaint #56-AS-20230731195356. During this visit, LPA's observed deficiencies not related to the complaint allegations.

During the visit, LPA verified staff members present. LPA observed staff member Manal Terab, Yusef Nofal, Najeh Hamed and Tyrone Powell present at the time of the visit. LPA researched Guardian to locate staff members associated to the facility to compare with staff present at the time of visit. LPA observed that staff member, was not associated to the facility. On 7/27/23, LPA contacted Administrator Najeh Hamed to inquire about staff member. Administrator confirmed S1's employment, but could not recall the staff member's date of hire.

While reviewing resident records, LPA observed that two, (2) resident's LIC602 - Physician's Report were out of date. Administrator acknowledged the LIC602's were out of compliance and agreed to have it addressed as soon as possible.

Based on observations and review of records, two (2) deficiencies are being cited to address the concerns listed above.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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 08/08/2023 12:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SUNSHINE BOARD & CARE
FACILITY NUMBER: 361880681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2023
Section Cited
CCR
87355(e)(2)

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87355 CRIMINAL RECORD CLEARANCE (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance ...
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Administrator agreed to review the Guardian website to update the list of staff members associated to the facility during the visit. LPA was able to verify the updated list. The POC was completed during the visit.
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This requirement is not met as evidenced by Based on observation & file review, licensee failed to ensure S1 was associated to the facility prior to working. LPA observed that S1 was not associated to the facility. This poses an immediate health & safety risk to the residents in care.
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Deficiency Continued: Administrator could not recall the exact date of hire for S1.
(g) Violation of Section 80019(e) will result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation for a maximum of 5 days by the Department."
Type B
09/15/2023
Section Cited
CCR87458(a)

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87458 Medical Assessment
Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.
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Administrator agrees to assist residents in care in coordinating doctor appointments to obatin a complete medical assessment by way of an LIC602 - Physician's Report. Administrator will submit completed copies of this documentation to the Community Care Licensing Office
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This requirement is not met as evidenced by:
Based on observations and record reviews, the Licensee failed to ensure resident in care maintained documentation of and were provided an annual medical assessment which poses a potential Health, Safety or personal rights risk to persons in care.
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to verify the task has been completed within the next 30 business days.
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
LIC809 (FAS) - (06/04)
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