<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601134
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:15:41 PM


Document Has Been Signed on 01/20/2023 02:15 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SUNSHINE CARE HOME FACILITY LLCFACILITY NUMBER:
415601134
ADMINISTRATOR:DE LA TORRE, JOCELYNFACILITY TYPE:
740
ADDRESS:2976 FLEETWOOD DRIVETELEPHONE:
(650) 720-1441
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
01/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Faye PobreTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day Licensing Program Analyst (LPA) Jaime Vado conducted an announced pre-licensing inspection visit. LPA met with licensee Faye Pobre who is the new owner of the facility who will be leasing the property from the land owner.

LPA toured the facility's building and grounds. This is a two level home. Upper level is care staff quarters and ground floor are where the residents live. All rooms for residents are non-ambulatory . All utilities are connected and functioning through out both buildings when inspected. Egress routes are clear and easily definable, labeled with exit signs, and egress route maps within the physical plant. Egress and emergency exit routes are free and clear of obstructions. COVID postings are in place on the ground floor of the facility. Hand washing signs are posted in resident bathrooms. Water temperature is tested at 106F in common bathroom on ground floor. LPA observed all resident rooms and they contain the required furniture outlined in regulations. Beddings and extra linens are observed in a storage cabinet in the garage. LPA observed a fire extinguisher as inspected as of 11/03/2023 and within operating range located near the dining table.

LPA inspected the kitchen and dining room area. Dining room area is observed as clean and in order. Both fresh food and frozen food supplies are inspected and observed as in place in the kitchen. Dry goods/emergency food supplies are in place also being stored in the garage. LPA observed medications as being locked and stored in an upper cabinet in the kitchen. Knives are locked in a drawer adjacent to the stove. First aid kit is observed as in place in the kitchen locked in the same cabinet as the medications. Resident medications are current and medications administration records as well. Resident temperatures are checked daily as well as staff.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued. LPA is recommending the license of the facility to be issued.

Component III is conducted and report is reviewed with licensee Faye Pobre.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1