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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881227
Report Date: 12/23/2022
Date Signed: 12/23/2022 03:05:39 PM

Document Has Been Signed on 12/23/2022 03:05 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 AND CARE IIFACILITY NUMBER:
361881227
ADMINISTRATOR:NOFAL, YUSEFFACILITY TYPE:
735
ADDRESS:1203 N. IRIS LANETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 10CENSUS: DATE:
12/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marylou, CaregiverTIME COMPLETED:
02:45 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Sunshine Board and Care Facility to conduct the Annual Inspection with a focus on infection control. LPA introduced self and stated purpose of the visit. LPA was greeted by caregiver, Marylou and granted entry. Upon entry, Marylou stated that she contacted Administrator Ahmed, who later arrived during the visit. COVID station was observed in the kitchen on the counter. Station included sign in sheet, hand sanitizer, disinfectant wipes and masks; made available to staff, visitors and residents.

During the inspection, LPA Coleman conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the Administrator and Caregiver wearing a mask during the visit. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. LPA reviewed resident records and interviewed Administrator.

During walk through LPA observed a resident seated in the living room with an IV bag hanging on an IV Pole attached to the resident. LPA was informed the resident had just discharged from the hospital and a Home Health Nurse makes visits to assist the resident with his IV medication. LPA was provided with the resident's chart and contact information for Home Health Agency.

No deficiencies were cited during this visit, however deficiencies maybe cited at a later date after additional information is gathered.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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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