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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880681
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:43:29 PM


Document Has Been Signed on 07/17/2024 03:43 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: 12DATE:
07/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Nick Hamed - AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit based on LPA observations made during complaint investigation #56-AS-20240712143356. LPA met with Administrator, Nick Hamed and discussed the purpose of the visit.

Based on Staff #1 (S1's) interview, LPA requested from Administrator Hamed to review S1's file for staff employment verification. Administrator Hamed stated that S1 did not have a complete employment verification, health screening, and CPR/first aid training on file. Administrator had one medication administration training on file for S1.

A deficiency is being cited (LIC809-D) in accordance with Title 22 of the California Code of Regulations. Administrator Hamed was informed that civil penalties will accrue $100 per day if the deficiency is not corrected by plan of correction due date.

An exit was conducted where this report and a plan of correction was discussed with Administrator Hamed. A copy of this report with Appeal Rights was provided to Administrator Hamed at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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 07/17/2024 03:43 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: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
87412(g)

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87412 Personnel Records(g)All personnel records shall be maintained at the facility and shall be available to the licensing agency for review...this requirement is not met as evidenced by:
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The Administrator stated that a copy of Staff #1's drivers license, Health screening, CPR/first training will be submitted to the Licensing Agency by POC due date.
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The licensee did not comply with the section cited above by not maintaining record of S1's required employment verification, health screening, and training on file for review, which poses a potential health, safety, and/or personal rights risk to residents in care
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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