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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603725
Report Date: 04/26/2023
Date Signed: 04/26/2023 01:07:27 PM

Document Has Been Signed on 04/26/2023 01:07 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SUNSHINE ARFFACILITY NUMBER:
374603725
ADMINISTRATOR:DOST, LEEDAFACILITY TYPE:
735
ADDRESS:738 AVENIDA AMIGOTELEPHONE:
(760) 536-3785
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 6CENSUS: 5DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Leena DostTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George conducted an unannounced annual/1 year required visit on the date and time noted above. LPA was granted entry by Caregiver Machona Merete, who was informed of the purpose of the visit. The Administrator Leena Dost arrived shortly after.

The facility is a two story home with (4) bedrooms and (3) bathrooms designated for the clients to use. LPA conducted a tour of the interior and exterior of the facility and observed the following:

Infection Control: The LPA observed the hand washing stations in the bathrooms. LPA also observed for the facility to have an adequate amount of Personal Protective Equipment (PPE) supplies. The facility has not submitted their Mitigation plan (LIC 808) that was to be submitted in January of 2021. deficiency will be cited.



Physical Plant: LPA observed the clients bedrooms which contained the required furniture. In the master bedroom LPA observed for their to be a chandelier light fixture with 5 light bulbs and 2 lamps that did not illuminate any light. The bulbs in the chandelier were not functioning and there were not any light bulbs in the other two lamps. Further observations made is the bathroom in the master bedroom has a broken handle on the sink closest to the shower. Deficiency will be cited. The interior and the exterior were observed to be clean, odor and clutter free. Other fixtures and furniture were observed to be in good repair. The facility does not have a pool or any other bodies of water on the premises. The water temperature was unable to be tested, as the hot water was shut off. Per the Administrator Ms. Dost, the facility was recently tented due to termites, for three days (4/22-4/24), and that the water company was coming by 4pm today (4/26) to turn the hot water back on. This information was confirmed by contacting the gas company. LPA inquired if the clients were not taking showers. Per Ms. Dost the clients were transported to the sister facility to take their showers. This information was also confirmed. LPA inquired as to the reason for bringing the client's back without the hot water and per Ms. Dost it was due to school and day programs and transportation not being able to make the extra three mile trip.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUNSHINE ARF
FACILITY NUMBER: 374603725
VISIT DATE: 04/26/2023
NARRATIVE
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LPA observed for there to be an additional room added to the garage as caregiver quarters. In addition there was a bed in the middle of the garage for a second staff to sleep on. Ms. Dost was informed that the facility sketch needed to be updated and that the middle garage could not be used as a bedroom. Deficiency cited.

Food Service: LPA observed the kitchen to be clean and possess equipment in good working condition. LPA observed the facility had the required 2-day perishable and 7-day non-perishable food supplies. LPA observed for there to be expired food items such as hard taco, shells, two bottles of mustard, biscuit mix and a container of beef broth. There was no deficiency cited as the expired food items were discarded during LPAs visit. The sharp and dangerous objects are kept locked in the kitchen underneath the sink. There are no firearms at the facility.

Care & Supervision/Administration: Adequate staff is available to provide the necessary care and supervision in care. Per Ms. Dost the facility is fully staffed. The facility's emergency exiting plans, emergency telephone numbers and personal rights were found posted in the facility on the wall inside of the the living room.

Record Review and client/Staff Files: LPA observed for staff # 3 (S3) CPR/First Aid Certification to be expired on 7/4/22. The (2) client files reviewed were observed to have the required documentation, as the Individual Program Plan (IPP) indicates the care that the client's need. Additionally, LPA conducted (1) staff interview. No client interviews were conducted as the clients were at program and a doctors appointment during LPAs visit.



Incidental Medical: LPA reviewed the medications for (2) clients and found that all resident medications were accounted for, with proper labeling, and medication administration log was found to be accurate and up to date.

Disaster Preparedness: Per Caregiver Machona the facility conducts their emergency drills every 6 months. The last fire drill was on 12/9/2022, The facility's fire alarms (5) and (2) carbon monoxide detectors were tested and are operable. LPA observed there to be two fire extinguishesr on the premises one located in the kitchen next to the dishwasher and the other upstairs in the hallway.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, Chapter 1 or 6 of the California Code of Regulations.
An exit interview was conducted, where a copy of this report, 809c, 809d and appeal rights were reviewed and provided to Administrator Leena Dost.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/26/2023 01:07 PM - It Cannot Be Edited


Created By: Javina George On 04/26/2023 at 12:14 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 ARF
FACILITY NUMBER: 374603725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in 1 out of 1 times as there was no mitigation plan submitted to the deparmtnes which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
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The Licensee agrees to complete the facility's mitigation plan. Proof is to be submitted to the department by 5pm on the due date indicated.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 1 out of 1 time as S3's CPR/First Aid certification expried on July 4, 2022, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
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The Licensee agrees to enroll S3 in CPR/FIrst Aid by 5pm on the due date indicated and to submit proof of the enrollment by 5 pm on the due date indicated.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/26/2023 01:07 PM - It Cannot Be Edited


Created By: Javina George On 04/26/2023 at 12:14 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 ARF
FACILITY NUMBER: 374603725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)(A)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.

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 in 1 out of 1 times, as S3 sleeps on bed that is located in the middle of the garage which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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The Licensee agrees to update the facility sketch and to move S3 to the staff quarters, proof is to be submitted to the department by 5pm on the due indicated.
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 1 ot of 1 time which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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The Licensee agrees to create a training binder for all staff training received that will be easily assessible for review. Proof is to be submitted to the department by 5pm on the due date indicated.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/26/2023 01:07 PM - It Cannot Be Edited


Created By: Javina George On 04/26/2023 at 12:43 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 ARF
FACILITY NUMBER: 374603725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)

Except for children's residential facilities, each clients shall have personal rights which include, but not limited to, the following: (2) to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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 noted above on at least 1 out of 1 time, as the ceramic handle on the sink is broken which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
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The licensee agrees to have the handle replaced. Proof is to be submitted to the department by 5pm on the due date indicated.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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