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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006629
Report Date: 07/08/2025
Date Signed: 07/08/2025 04:54:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2025 and conducted by Evaluator Eboni Bentley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250630152805
FACILITY NAME:SUNSHINE GUEST HOMEFACILITY NUMBER:
306006629
ADMINISTRATOR:HSI, CATHERINEFACILITY TYPE:
740
ADDRESS:10188 CARDINAL AVETELEPHONE:
(949) 275-9107
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 3DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator - Catherine HsiTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not provide equipment and supplies for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Eboni Bentley and Jessica Cho arrived at the facility unannounced to initiate the complaint investigation into the above allegation. LPAs were greeted and granted entry after stating the purpose of the visit to Caregiver (CG) Luis Franco and obtained the following documentation: Resident Roster, Personnel Report Summary, Face Sheets, one of three residents’ Admission Agreements, and one of three residents’ Physician’s Reports. Licensee (LI) Nhut Nguyen arrived shortly after to assist with the investigation and has agreed to submit the remaining documents via email by 5pm July 9, 2025.

Regarding the allegation, Facility did not provide equipment and supplies for residents, the following was determined based on observations, interviews, and record review:

The resident census is three (3). Based on LPA’s observations of the bedrooms of three residents between 3:00-3:35pm, LPAs observed all required items in the bedrooms which includes the hospital bed, chair, lamp, chest of drawers, and a nightstand.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20250630152805
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/08/2025
NARRATIVE
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LPAs also observed sufficient clean linens in good repair, in each of the bedroom closets, bathrooms, and in the washer and dryer. Also, in the washer and dryer, there were additional towels and linens being washed. There were also seven new sets of unopened packages of linens stored in a closet.

Based on the interviews, three out of the three residents, the facility provided all furniture in the room, with the exception of Resident #1 (R1) whose family provided an additional wooden nightstand and wooden chest of drawers, upon move-in on June 29, 2025.

Based on interview with LI Nguyen, the facility did not have/provide any chest of drawers in any of the resident bedrooms prior to July 2, 2025. LI confirmed ordering four chest of drawers from Walmart on July 2, 2025 and provided proof of receipt with purchase order date and delivery date of July 2, 2025. LI proceeded to show LPAs four out of four chest of drawers delivered and placed in each residents’ bedroom. It is determined that all three residents were without a dresser until July 2nd, therefore, based on the information gathered during the investigation, through interviews and record review, the preponderance of evidence standard has been met and is deemed SUBSTANTIATED.

A deficiency is being cited as per the California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached LIC9099-D.

An exit interview was conducted with Licensee Knut Nguyen, and a copy of this report including the LIC9099D, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250630152805
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2025
Section Cited
CCR
87307(a)(3)
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87307 Personal Accomodations and Services (a)(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.
This requirement was not met as evidenced by:
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Proof of purchase order for four dressers were provided with a delivery date of July 2, 2025. Licensee stated that an Acknowlegement of Understanding of the said deficiency will be emailed to LPA by POC due date.
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Based on LPAs' record review and interviews, facility did not provide equipment and supplies for residents, including chest of drawers in the bedrooms for three out of three residents which poses a potential Personal Rights risk to persons in care.
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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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3