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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880681
Report Date: 08/05/2021
Date Signed: 08/05/2021 01:02:05 PM

Document Has Been Signed on 08/05/2021 01:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SUNSHINE BOARD & CAREFACILITY NUMBER:
361880681
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:720 N LINDEN AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 12CENSUS: 12DATE:
08/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Estrella HellerTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPAs) Melody Brown and Natalie Gayoso arrived to the facility to investigate allegations made against the facility. In the process of conducting the investigation it was discovered that the facility allowed two (2) caregivers, Staff 3 (S3) and Staff 4 (S4) to work at this facility without fingerprint clearance. It appears that S3 and S4 have been allowed to work at the facility for the last 3 months. Although the administrator claims S3 and S4 were sent to get fingerprint cleared, there is no proof provided that S3 and S4 were cleared to be allow to work at the facility. Therefore, this facility will be cited for civil penalties.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2021
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
Document Has Been Signed on 08/05/2021 01:02 PM - It Cannot Be Edited


Created By: Melody Brown On 08/05/2021 at 12:22 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUNSHINE BOARD & CARE
FACILITY NUMBER: 361880681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited
CCR
87411(g)(1)

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87411 Personnel Requirements Prior to employment or initial presence in the facility, all employees... shall obtain a California clearnace...
This requirement is not met as eveidenced by:
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Licensee will remove S3 and S4 from the facility immediately. Licensee will submit an LIC 9182 along with clear photo ID by mail or in person to CCL by POC date 08/06/2021.

A civil penalty will be assessed.
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based on interviews, licensee failed to ensure S3 and S4 were fingerprinted and associated to the facility prior to employment.This is an immediate health and safety risks to the resident 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021


LIC809 (FAS) - (06/04)
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