306006676-5-15-2026-22-AS-SHAN-DU4PTZ-20260515113647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006676
Report Date: 05/15/2026
Date Signed: 05/15/2026 11:37:25 AM

Document Has Been Signed on 05/15/2026 11:37 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SUNSHINE CARE HOME		FACILITY NUMBER:	306006676
ADMINISTRATOR/ DIRECTOR:	ASIS, AIKO		FACILITY TYPE:	740
ADDRESS:	1017 N GILBERT ST		TELEPHONE:	(714) 469-9435
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 6		CENSUS: 2	DATE:	05/15/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:19 AM
MET WITH:	Aiko Asis		TIME VISIT/ INSPECTION COMPLETED:	11:46 AM

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	On May 15, 2026, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit at the facility for the purpose of completing the annual inspection. LPA Haddadin was greeted and granted entry by Administrator (AD) Aiko Asis. The facility is a single-story residence consisting of four bedrooms and two restrooms. The approved capacity is six non-ambulatory residents, of whom one may be bedridden. Hospice care may be provided for up to two residents. At the time of the visit, there were two residents in care. LPA conducted a comprehensive interior inspection and found the facility to be clean, safe, and sanitary. Resident bedrooms were appropriately furnished with a bed, clean linens, a chair, closet space, and adequate lighting. An adequate supply of extra linens and hygiene products was available for residents. Restrooms were stocked with soap and paper towels, and the hot water temperature measured 105.3 degrees Fahrenheit in both bathrooms. Hallways and walkways were clear of obstructions. Chemicals and toxins were secured in the garage and under the kitchen sink. Knives and sharps were secured in a locked kitchen cabinet. Medications were centrally stored in a locked kitchen cabinet and were inaccessible to residents in care. The first aid kit was located in the kitchen and contained the required components. {*CONTINUE 809C*}

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNSHINE CARE HOME	FACILITY NUMBER: 306006676
	VISIT DATE: 05/15/2026

NARRATIVE

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The fire extinguisher was fully charged, with the pressure gauge arrow within the green zone, and the service tag indicated it was last serviced on August 4th, 2025. Staff tested the smoke detectors and carbon monoxide detectors during the visit, and all units were operational. The facility also maintained a two-day supply of perishable food items and a seven-day supply of non-perishable food items.
LPA toured the exterior grounds and found the perimeter and outdoor walkways to be free of obstructions and safety hazards. A shaded outdoor seating area with outdoor furniture was available for resident use. The perimeter gate was self-latching and opened properly to allow for safe evacuation if needed. No bodies of water were observed on the premises.
LPA reviewed two resident files, associated medications, and two staff files. No discrepancies were observed, and all reviewed files contained the required documentation. Facility operational logs indicated that the facility was current with required quarterly fire drills. The most recent fire drill was conducted on March 6, 2026. The administrator’s certificate expires on November 8, 2027.
Based on observations made during today’s visit, no deficiencies are being cited under Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Aiko Asis, and a copy of this evaluation report was provided on-site.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC809 (FAS) - (06/04)

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