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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880681
Report Date: 08/11/2021
Date Signed: 08/11/2021 12:19:59 PM

Document Has Been Signed on 08/11/2021 12:19 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:
08/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ahmad "Adam" Abdallatef - Designated Facility RepresentativeTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to investigate two complaints (#18-AS-20200803114859 & #18-AS-20210805155349). During LPA Colvin's investigation of the complaints, LPA Colvin observed some additional deficiencies. LPA Colvin met with Facility Representative Adam Ahmad "Adam" Abdallatef at the facility and Administrator/Licensee Najeh "Nick" Hamed was contacted via telephone. LPA Colvin advised Adam and Nick of the purpose of the visit.

During LPA Colvin's investigation of a complaint (#18-AS-20200803114859), LPA Colvin was provided with an Eviction Notice from staff member (S1) for a prior resident (R1). In review of this Eviction Notice, LPA Colvin observed the following issues: 1. Notice was not provided to Licensing when given to the recipient, 2. Notice did not contain the required resources for the resident. The Notice was alleged to have been provided to R1 on 4/29/20, as indicated on the date for the typed notice, as well as the date signed by designated staff. Community Care Licensing (CCL) was not provided with a copy of this Notice until 6/24/21 when LPA Colvin was discussing the issues at hand in the complaint investigation with S1. Title 22 Regulations require facilities to provide CCL with copy of all Eviction Notices within 7 days after they are supplied to the resident. Deficiency cited. Additionally, LPA Colvin observed that while the Notice did provide a reason allowable under Title 22 for eviction, the Notice did not supply R1 with any resources required to aid R1 with finding alternative housing. Since the eviction notice was not upheld and the Licensee assisted with finding a new facility for R1 to move to, LPA Colvin will not be issuing a deficiency and instead will be issuing a Technical Violation Advisory Note (TV). Additionally, the Notice should have also detailed the specifics for why R1 was being provided with an eviction notice, whereas the notice provided to LPA Colvin only states "recent misbehavior and complaints". Deficiency cited.

Lastly, the base incident of the complaint (#18-AS-20200803114859) was regarding a physical altercation between three residents on 5/19/20, one of which was taken into custody by law enforcement.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 & CARE
FACILITY NUMBER: 361880681
VISIT DATE: 08/11/2021
NARRATIVE
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A Special Incident Report (SIR) was not submitted to CCL until 8/11/20, when it was requested by LPA Colvin for the purpose of investigating the situation. Facilities are required to report incidents which pose a risk for safety of any resident within seven (7) days. SIR was not submitted for nearly three (3) months. LPA Colvin will be issuing a Technical Violation Advisory Note (TV) instead of a deficiency since the facility had copies of the incident reports in the file with notations that they were faxed to Licensing. LPA Colvin consulted with Licensee/Administrator over possibly mailing the SIRs or emailing them to Licensing's office email address at CCLDASCPRiversideRO@dss.ca.gov and to keep additional records/documentation to show proof of submission to Licensing.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on the LIC809D.

A copy of this report was provided along with LIC809D, LIC9102 Technical Violation, and appeal rights during the exit interview with Facility Representative Adam Ahmad "Adam" Abdallatef. LPA Colvin will be emailing a copy of the report to Administrator/Licensee Najeh "Nick" Hamed as well.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2021 12:20 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/11/2021 at 11:29 AM
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: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2021
Section Cited
CCR
87224(f)

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Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by:
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Licensee agrees to review Title 22 Regulation Section 87211 regarding Reporting Requirements. Licensee to self-ceritfy to LPA Colvin once complete. Plan of Correction due by 8/25/21.
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Based on record review, the Licensee did not comply with the above regulation with one resident (R1). R1 was provided with an eviction notice dated 4/29/20, but Licensing was not provided with a copy of the eviction notice until 6/24/21. This was a potential personal rights violation for R1.
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Type B
08/25/2021
Section Cited
CCR87224(d)

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Eviction Procedures: (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by:
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Licensee agrees to review Title 22 Regulation Section 87224 regarding Eviction Procedures. Licensee to self-ceritfy to LPA Colvin once complete. Plan of Correction due by 8/25/21.
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Based on record review, the Licensee did not comply with the above regulation with one resident (R1). R1 was provided with an eviction notice that only stated "recent misbehavior" with no further details. This was a potential personal rights violation for R1.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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