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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700653
Report Date: 11/23/2022
Date Signed: 11/27/2022 09:30:10 PM

Document Has Been Signed on 11/27/2022 09:30 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNSHINE RESIDENTIAL IIIFACILITY NUMBER:
502700653
ADMINISTRATOR:AMOAH, MARYFACILITY TYPE:
735
ADDRESS:1233 FAWN LILY DRIVETELEPHONE:
(510) 935-8503
CITY:PATTERSONSTATE: CAZIP CODE:
95363
CAPACITY: 6CENSUS: 4DATE:
11/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Mary AmoahTIME COMPLETED:
12:15 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
Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check.

LPA confirmed that R1 is at the facility, has medication and is adjusting to the new environment.

LPA reviewed new resident's facility file. During the review LPA observed that R1 has current information including a recent IPP, Physician's report and a current medication administration record. R1 is living in a level 4I home, has some vision impairment. R1 has a three weeks supply of medication.

Health and Safety check included food supply, physical plant and staffing. based on this inspection/visit the facility is in compliance.

No deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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