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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320337
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:58:38 PM

Document Has Been Signed on 11/21/2024 02:58 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SUNSHINE BOARD AND CARE HARBOR LLCFACILITY NUMBER:
198320337
ADMINISTRATOR/
DIRECTOR:		PUNZALAN, RUSTICOFACILITY TYPE:
740
ADDRESS:23411 HALLDALE AVETELEPHONE:
(424) 378-1145
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Assistant Administrator Ruby PunzalanTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 11/21/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Assistant Administrator Ruby Punzalan.

The facility is licensed to operate for six (6) non-ambulatory residents ages 60 and over of which one (1) may be bedridden in room #3. It has a hospice waiver for six (6) residents.


The facility is a one-story house located in a residential neighborhood and consists of four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms and a two-car garage. The home also consists of a living room, dining room, and kitchen. The facility is clean, sanitary, and in good repair.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions.
Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUNSHINE BOARD AND CARE HARBOR LLC
FACILITY NUMBER: 198320337
VISIT DATE: 11/21/2024
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced October 9, 2024 was observed in the living room, the hallway, and in the kitchen area. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

Five staff records were reviewed, and five out of five staff records had the required criminal record clearances or criminal record exemptions.

Five resident records were reviewed, and five out of five resident records had medical assessments. Two residents’ medication was reviewed.

No deficiencies are being cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with the Assistant Administrator Ruby Punzalan.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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