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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881227
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:52:56 PM

Document Has Been Signed on 12/17/2024 02:52 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SUNSHINE BOARD AND CARE IIFACILITY NUMBER:
361881227
ADMINISTRATOR/
DIRECTOR:		NOFAL, YUSEFFACILITY TYPE:
735
ADDRESS:1203 N. IRIS LANETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 10CENSUS: 10DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Staff Malik SalemTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with staff Malik Salem and was granted entry to the facility. The facility is a (5) bedroom (3) bathroom home and with a kitchen/dining area, living room and attached garage. The facility is an Adult Residential Facility (ARF). Licensed capacity is (10) current census (10). LPA was accompanied by Administrator Najeh Hamed to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature at 73 degrees. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 105 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. First aid kit and book were observed.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUNSHINE BOARD AND CARE II
FACILITY NUMBER: 361881227
VISIT DATE: 12/17/2024
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Record Review: LPA reviewed (5) client files for admission agreements, updated physician reports, and needs and services plans. LPAs reviewed (5) client medications. LPA observed for Client #1 (C1) PRN medication to be not be dated, signed or response given for PRN medication. Additionally, Client #1, Client #2, Client #3, Client #4, Client #5 daily AM medications to not be documented in Medical Administration Record (MAR).Deficiency will be issued. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Based on the observations made during today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), (LIC809C), (LIC809D) was discussed and provided to Administrator Najeh Hamed and Appeal Rights were printed.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2024 02:52 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 12/17/2024 at 02:05 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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by not ensuring Client #1
s medication PRN was dated, signed and resposne was given, as well as Client #1, Client #2, Client #3, Client #4 and Client #5 medication was dated and signed in Medication Administration Record (MAR), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Licensee stated they will document future PRN medication and send photo documentation of AM medications being given to clients by Plan of Correction (POC) due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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