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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801931
Report Date: 06/11/2021
Date Signed: 06/11/2021 10:59:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNSHINE HEALTH PLACE 2FACILITY NUMBER:
565801931
ADMINISTRATOR:SAM MARONFACILITY TYPE:
740
ADDRESS:1482 NORMAN AVENUETELEPHONE:
(805) 304-5960
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cilva ToumeTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 9:45am. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Cilva Toume and explained the reason for the visit.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed the single-room bedrooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. RESTROOMS: Restrooms are clean, sanitary and in operating condition with grab bars and non-skid surfaces. COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. The LPA observed all the required postings in the dining room and the hallway. During today's visit, the Administrator printed and posted the Department Provider Information Notices (PINs).

INFECTION CONTROL: The LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:


- Continue to check and record temperatures for staff and residents.

No deficiencies cited at this time. Exit interview conducted. Signatures obtained.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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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