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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003418
Report Date: 04/26/2024
Date Signed: 04/26/2024 01:22:43 PM

Document Has Been Signed on 04/26/2024 01:22 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SUNSHINE HOME CAREFACILITY NUMBER:
306003418
ADMINISTRATOR/
DIRECTOR:		ESTER DELA CRUZFACILITY TYPE:
740
ADDRESS:2428 WEST AVENUETELEPHONE:
(714) 525-1566
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 5DATE:
04/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Ester Dela CruzTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On April 26, 2024, at 9:10 am, Licensing Program Analyst (LPA) Edward Kim and Licensing Program Manager (LPM) Lourdes Montoya conducted a continuation visit for a required 1-year annual visit. LPA Kim and LPM Montoya were greeted and gained entry to the facility by staff. Administrator Ester Dela Cruz arrived 10:00 am.

LPA Kim conducted a record review on resident files (R1-R5) and staff files (S1-S2). LPA Kim conducted a resident interview (R5) and staff interviews (S1-S3). LPA Kim reviewed resident medications and medication administration record.

Deficiencies were cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). Civil Penalty assessed.

An exit interview was conducted with AD DeLa Cruz and a copy of this report and appeal rights provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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Document Has Been Signed on 04/26/2024 01:22 PM - It Cannot Be Edited


Created By: Edward Kim On 04/26/2024 at 12:25 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE HOME CARE
FACILITY NUMBER: 306003418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(b)
Care of Bedridden Residents
(b) A facility shall notify the local fire jurisdiction within 48 hours of accepting or retaining any bedridden person, as specified in Health and Safety Code Section 1569.72(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA Kim and LPM Montoya observed two (2) resident files, R4 and R5, are bedridden. However facility does not have fire clearance for bedridden residents. This poses an immediate health and safety risk to persons in care.
POC Due Date: 04/27/2024
Plan of Correction
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Licensee agreed to the section cited above. Licensee will submit a LIC 200, with $25, and obtain fire clearance for bedridden. Proof of correction of the above deficiency will be submitted to CCLD via email to edward.kim@dss.ca.gov by the POC due date, 4/27/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/26/2024 01:22 PM - It Cannot Be Edited


Created By: Edward Kim On 04/26/2024 at 12:44 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE HOME CARE
FACILITY NUMBER: 306003418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(d)
87208 Plan of Operation (d) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview with licensee, facility does not have a plan of operation for accepting and retaining bedridden persons.This poses a potential health, safety, and/or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee agrees to the section cited above. Licensee agrees to update in writing the new plan of operation to include information for accpeting and retaining bedridden persons and send documents to CCLD via email to edward.kim@dss.ca.gov by POC due date May 3, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
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