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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880681
Report Date: 11/06/2025
Date Signed: 11/06/2025 04:14:52 PM

Document Has Been Signed on 11/06/2025 04:14 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SUNSHINE BOARD & CAREFACILITY NUMBER:
361880681
ADMINISTRATOR/
DIRECTOR:		HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:720 N LINDEN AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 12CENSUS: DATE:
11/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:Malik Salem, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Sunshine Board and Care, Residential Care facility for the Elderly, unannounced to conduct an Annual Inspection. LPA was greeted and granted entry by Caregiver, Berlian Siagian. LPA met with House Manager, Malik Salem and Administrator, Ahmad Abdallatef. LPA introduced self and stated purpose of the visit. Malik accompanied LPA on a tour of the facility and provided records for review.

The facility has 8 bedrooms in total. 6 resident rooms, 2 staff rooms, 7 bathrooms, kitchen, dining area, living room, staff lounge, (attached garage) and 2 side pathways on the exterior. LPA conducted a general overall inspection, which included, but was not limited to, the following:



Physical Plant: The facility is approved to have 12 ambulatory residents, 2 of which may be non-ambulatory. The current census is nine (9) resident and three (3) resident are currently at the Day Program. The facility is operating at the capacity approved by Community Care Licensing (CCL). Pathways were observed free of clutter and obstructions. The facility was maintained in comfortable temperature of 74 degrees Fahrenheit. Water temperature measured at 110.4 and 108.5 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, adequate storage and sufficient lighting, and seating. LPA inspected resident bathrooms. Bathrooms were observed to in order and included functional appliances. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Administrator reports disaster drills are conducted quarterly. Posters such as; the personal and resident rights, let us know, and disaster/evacuation plans, facility license, staff and resident roasters were posted in common areas. LPA observed cleaning supplies in three (3) out of six (6) residents bathrooms/bedrooms unsecured. A deficiency was cited. The facility does have a designated area to secure cleaning supplies, toxins, sharps, and other dangerous items and were observed to be kept secure and inaccessible to residents. LPA observed that resident and staff files are kept secure in a designated securable cabinet in the facility's staff area. Medications were observed secure and inaccessible to residents. Emergency and first aid kits were observed and readily available for residents in care.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUNSHINE BOARD & CARE
FACILITY NUMBER: 361880681
VISIT DATE: 11/06/2025
NARRATIVE
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Food Service: Non-perishable and perishable food supply is adequate for amount of residents in care. The facility has a posted food menu; which is published on a monthly basis for breakfast, lunch, dinner and snacks. Facility offers its resident a variety of food items such as fruits, canned goods, dry foods, chips, milk, eggs, beverage and frozen meals.. Dishes, cups, and utensils were observed to be clean and in proper storage and in adequate amounts. Emergency food and water supply were also observed.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members currently employed in the facility have criminal/fingerprint/background record clearance through the department.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. Three, (3) out of three, (3) resident files were complete with all documents needed. LPA also reviewed three, (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA observed one (1) out of three (3) staff were missing their health screen and TB test results. A deficiency was cited. Fire extinguisher last inspected 2025. LPA completed a random audit of three residents MARS. LPA observed two (2) out of three (3) resident were missing an initial, medication was not listed on the centrally stored medication list or the MARS. A deficiency cited.

Based on observations, interviews and record reviews, three deficiencies and will be cited per Title 22, California Code of Regulations. An exit interview was conducted. A copy of this report LIC809, LIC809C, LIC809D, and appeal rights was read/reviewed with House Manager, Malik Salem; signature acknowledges understanding and receipt of report.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/06/2025 04:14 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/06/2025 at 03:37 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: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above three (3) out of six (6) residents bedrooms and or bathrooms by not ensuring the cleaning supplies were secured and locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Administrator agrees to review the regulation cited above, and provided an statement of understanding acknowledging the regulation. Administrator also agrees to complete a training with all staff regarding the regulation and a list of all participate in the training by 11/20/2025 to LPA.
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in two (2) out of three (3) residents in care by not ensuring that all medication was listed on the centrally stored medication log, and all dispensed medication has been properly initialed by staff that dispensed the medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Administrator agrees to review the regulation cited and complete a statement of understanding. Review and correct the MARS and Centrally Stored Medication log. Conduct a training with staff regarding medication to include centrally stored medication logs, medication storage, proper medication practices, and commonly known medication errors by 12/1/2025 to LPA Farlow.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 04:14 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/06/2025 at 03:37 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: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in one (1) out of three (3) staff by not ensuring all staff file are complete with health screening and TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2025
Plan of Correction
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Administrator agrees to review all personal file and make sure all file are accurate and complete with required forms.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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