<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006629
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:43:15 PM

Document Has Been Signed on 01/16/2025 04:43 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 GUEST HOMEFACILITY NUMBER:
306006629
ADMINISTRATOR/
DIRECTOR:		HSI, CATHERINEFACILITY TYPE:
740
ADDRESS:10188 CARDINAL AVETELEPHONE:
(949) 275-9107
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 0DATE:
01/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Nhut Thanh Nguyen & Catherine HsiTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to the facility to conduct a Pre-Licensing inspection. LPA identified herself and was granted entry into the home by Applicant Nhut Thanh Nguyen and Administrator Catherine Hsi. An initial application to operate an Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing on 09/13/2024 for a capacity of six (6) Residents. Administrator Catherine Hsi has an Administrator certificate valid until 08/25/2025. Upon entry, facility appears clean, safe and sanitary.

LPA along with Applicant toured the facility and observed the following: Structure: Facility is a one story, 4 bedroom, 2.5 bathroom house with a two car attached garage. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Resident: Two rooms will be single occupancy and other two will be double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: Resident bathrooms have a working toilet and wash basin. Facility has sanitizer/soap in the bathrooms. Linens & Hygiene Supplies: Facility has adequate bedding, towels and hygiene supplies for Residents in care. Emergency Phone Numbers and Exit Plan: Emergency plan/phone numbers will be located in facility entrance. Food Service: Applicant understands to have a 2 day supply of perishables and a 7 day of non-perishables at all times when Residents are present. There are no Residents present during this inspection. LPA observed ample emergency food and water as well as a facility menu. Smoke Detectors: Smoke detectors/carbon monoxide detectors were tested operational. Fire extinguishers is mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/Sharps: Facility has secured area for toxins/sharps under kitchen sink and kitchen cabinet. Water Temperature: Tested and hot water temperature was within regulatory requirements.

(cont...LIC809C)
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUNSHINE GUEST HOME
FACILITY NUMBER: 306006629
VISIT DATE: 01/16/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Medications, First-Aid Kit & Book: First aid kit observed contained all required items, including First Aid Manual. Medication will be stored in dining area locked cabinet and will use a Medication Administration Record.

Resident & Staff File: Records to be stored in living room display cabinet. Reading Material, Games, and Equipment: Facility has a variety of board games, music, bingo and cards games.

Backyard: LPA observed a swimming pool that is fenced and inaccessible. LPA observed a clean backyard and a covered patio with plenty of seating for Residents and visitors. Exit gate observed unlocked.

Fire Clearance: Approved on 10/14/2024. Rooms 1 thru 4 are non-Ambulatory, Room 4 is Bedridden. Facility will have no Live-in staff.

The Component III was completed during today's visit. Applicant and Administrator demonstrated and exhibited a clear concise comprehensive knowledge of medication protocols, documentation, and wound preventative care.

The Pre-Licensing evaluation has been completed. It appears this facility meets the requirements for licensure. The license will be granted upon completion of a final review and approval from the Application Specialist.

An exit interview was conducted with Applicant and the report will be sent to email on file.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2