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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608474
Report Date: 09/22/2021
Date Signed: 09/23/2021 07:26:12 AM

Document Has Been Signed on 09/23/2021 07:26 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUN CARE HOMESFACILITY NUMBER:
197608474
ADMINISTRATOR:STEPHANIE FLORESFACILITY TYPE:
740
ADDRESS:18725 SHOENBORN STREETTELEPHONE:
(818) 384-7456
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 6DATE:
09/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Emma ParicoTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted a case management visit in conjunction with complaint # 31-AS-20210917161143. During file review the following was discovered.

1:00 pm Upon review of staff files there were two staff not associated to the facility, The administrator Emma Parica states she knows about the annual Personnel register and that it was sent to the facility . She was not able to review it. There was no staff schedule to determine staff coverage and who was working upon entry. A file review was conducted and each staff was working at facility for over 5 days. A citation and civil penalty was assessed.

11 am during the LPA tour of the facility, the following was observed
The register of residents had not been updated since 2019. LPA requested a copy of the register and the staff schedule but she did not have anything on file. NO LIC500 was completed. They submitted to LPA by fax a list of their schedule. The mitigation plan that was approved was requested but no copy on file.

The medication cabinet in the kitchen was open and accessible. There were also medication in the plastic cup that was accessible. The drawer that had the knives and scissors was unlocked and accessible. Staff foods were observed open and un packaged in the microwave and oven.

The dining area where the residents eat had food drippings on the plastic cover and was unclean. Light bulb in the kitchen area was out and the light switches were unclean and had debris. The residents rooms were checked and the night stands had no hand sanitizers and had food drippings, debris and not dusted. Residents cups were observed unclean with stains and dirty water.

LPA will return to issue additional citations at a later date due to time constraints. Report was signed, exit interview conducted. Appeal rights given. Report to be emailed to Administrator.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Angelica Arambulo
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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Document Has Been Signed on 09/23/2021 07:26 AM - It Cannot Be Edited


Created By: Angelica Arambulo On 09/22/2021 at 01:35 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUN CARE HOMES
FACILITY NUMBER: 197608474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2021
Section Cited
CCR
87355(c)(1)

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87355 Criminal Record Clearance
A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:
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The administrator shall submit transfer request to have staff associated to the facility. LIC 9182 to be submitted along with and LIC508 and staff ID or CDL.
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This requirement is not met as evidence by LPA record review that staff 2 and 3 are not associated to the facility,
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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:Eva Miller
LICENSING EVALUATOR NAME:Angelica Arambulo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021


LIC809 (FAS) - (06/04)
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