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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801931
Report Date: 05/10/2022
Date Signed: 05/10/2022 11:25:08 AM


Document Has Been Signed on 05/10/2022 11:25 AM - 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, 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:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Cilva ToumeTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 10:10 a.m. 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 LPA 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. The LPA observed appropriate hand-washing signs in the restrooms. COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Passageways were clean and clear of obstructions. No bodies of water were noted in the backyard. The LPA observed all the required postings in the dining room and the hallway that promoted cough etiquette, signs and symptoms of COVID-19, and appropriate hand hygiene. Medications are kept locked inaccessible in the hallway cabinet. Hand sanitizer was available for staff and resident use. The LPA observed that the Department Provider information Notices (PINs) were posted on a board in the kitchen.

INFECTION CONTROL: 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. The facility can designate a single isolation room if the facility has a confirmed case of COVID-19. The Administrator continues to conduct testing, regardless of vaccination status. The facility’s policies and procedures as it pertains to infection control are adequate.

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: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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