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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881227
Report Date: 12/18/2023
Date Signed: 12/18/2023 02:44:47 PM

Document Has Been Signed on 12/18/2023 02:44 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: 3DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Maria Virata, CaregiverTIME COMPLETED:
03:00 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Sunshine Board and Care II Facility, unannounced to conduct the Annual Inspection. LPA introduced self and stated purpose of the visit. LPA was greeted and granted entry by Maria Virata, Caregiver, who provided LPA provided space to work. Caregiver contacted Administrator, Adam Hamed to let them know of LPA's visit. LPA Coleman conducted a tour of the facility, inside and outside, and observed the following:

Facility: The Facility is approved for ten, (10) ambulatory residents. Staff report the current census was 3 when LPA arrived. The facility does house residents who utilize home health services at this time

Physical Plant: LPA Coleman observed the facility's temperature to be comfortable at 73 degrees Fahrenheit. The facility contained sufficient lighting in and throughout the residence. The facility is equipped with functional smoke/fire alarms, carbon monoxide detectors. LPA observed a fire extinguisher in the kitchen, last inspected October 2023. Administrator, who arrived later during LPA visit reports that fire/disaster drills are conducted on a monthly basis. LPA observed no pool or body of water on facility grounds.
Food Service: Nonperishable and perishable food is sufficient for number of residents in care. Staff was in the process of preparing dinner during LPA visit. LPA observed that food is being prepared and stored properly. Facility has a variety of food, snacks and fresh fruits available for residents in care. LPA observed that sharps and chemicals (cleaning supplies) are kept secure and inaccessible to residents in care.

Care & Supervision: Facility has sufficient care staff; who assist residents 24 hours and 7 days a week. 1 staff member resides inside the facility. According to staff records, all staff files contained verification of their annual training. The Administrator's Administrator Certificate was observed in compliance. Please see LIC9099-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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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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 AND CARE II
FACILITY NUMBER: 361881227
VISIT DATE: 12/18/2023
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Record Review and Resident Files: LPA Coleman reviewed records for five, (5), residents currently living at the facility. Resident records are complete with Physician's Reports and Needs and Services Plans. Out of 5 resident files, two, (2) residents did not have updated Physician’s Reports.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, Personal & Resident Rights and facility license are posted in the hallway of the facility. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medications are centrally stored securely in a kitchen cabinet. LPA Coleman did not observe any medication errors during the resident file review of records.

Based on review of records a deficiency is being cited to address the Resident Records. Technical Violations will be issued to address medications kept in the refrigerator. Exit interview conducted and copy of this report was provided to Facility Representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2023 02:44 PM - It Cannot Be Edited


Created By: Amber Coleman On 12/18/2023 at 02:36 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUNSHINE BOARD AND CARE II
FACILITY NUMBER: 361881227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
80069 - Client Medical Assessment
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

(1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records the licensee did not comply with the section cited above iby not ensuring all residents in care had complete up to date medical assessments (Physician's Reports) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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Administrator agrees to assis the residents with making and keeping appointments with their Primary Care Pysicians in order o get their Physician's Reports completed. Once completed Administrator agrees to submit verification to the Community Care Licensing Office within the next 30 business days.
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:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023


LIC809 (FAS) - (06/04)
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