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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408218
Report Date: 03/20/2025
Date Signed: 04/01/2025 03:37:39 PM

Document Has Been Signed on 04/01/2025 03:37 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 HOME IIFACILITY NUMBER:
366408218
ADMINISTRATOR/
DIRECTOR:		ALBAO, LOURDESFACILITY TYPE:
740
ADDRESS:2158 SYCAMORE AVENUETELEPHONE:
(909) 874-8114
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 2DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Tessie Martinez, Caregiver and Rosario Nicolas, Licensee.TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 03/20/2025, at 9:30 AM, Licensing Program Analyst, LaVette FArlow, (LPA) arrived at the Sunshine Home II, unannounced to conduct the Annual Inspection. LPA observed caregiver Tessie Martinez outside the home and was greeted by Care Staff, and granted entry. Caregiver Tessie contacted Licensee, Rosario Nicolas to notify of LPA visit.

LPA conducted a general overall inspection with care staff, which included, but was not limited to, the following:

Physical Plant: At 9:38 AM, LPA conducted a tour of the physical plant the facility is comprised of 3 Resident Rooms, 1 Staff Bedroom, 2 Bathrooms, Kitchen, Dining Room, Living Rooms, Attached Garage, and Backyard. The facility maintains a partnership with the Inland Regional Center at a Level III (3). The facility is approved for six, (6) non-ambulatory, 1 bedridden resident and 1 wheelchair bound resident. LPA was informed the current census at the time of visit was 2. Resident were at their prospective day programs. The facility is operating in the capacity approved by Community Care Licensing (CCL). Pathways inside and outside of the facility were free of obstructions. The facility was maintained at a comfortable temperature 74 degrees Fahrenheit. Resident Rooms were observed orderly and contained all required furnishings such as beds with proper linens, night stands, adequate storage space and lighting. The hallway leading to the bedrooms and bathroom lighting is low. Technical advisory issued. The facility is equipped with functional smoke/fire detectors and carbon monoxide alarms. Administrator reports fire/disaster drills are ran on a monthly basis. Fire extinguisher was observed near the kitchen; last inspected March 2025. Backyard provides sufficient space, shady and adequate seating. Pathways free of clutter and obstruction. At 10:01 AM, LPA observed the screen attached to the sliding glass door leading from the staff office area to the backyard is broken and hanging off the track. LPA Farlow also, observed the exit to the backyard area with the broken screen blocked with boxes and files, obstructing the exit. LPA informed the caregiver of the safety concerns. This poses a safety hazard and a deficiency was cited. The facility has two exit doors leading to the backyard. When Licensee Rosario arrived LPA informed her of the safety concern and the screen was fixed immediately, and licensee stated the boxes will be removed. In the garage, the facility maintains their laundry room, emergency supplies, Personal Protective Equipment, cleaning supplies, refrigerators for extra food storage and emergency food and water supply.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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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 HOME II
FACILITY NUMBER: 366408218
VISIT DATE: 03/20/2025
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The garage was observed to be secure inaccessible to residents in care. A hallway closet provided a secure space for the resident's medications and records. Staff files are also maintained securely in the staff area. LPA observed and tested the water temperature and the water tested at 126.4, 126.3 and 110.8. A technical violation issued. The facility maintain a log documenting a weekly check of the water temperature. The licensee immediately call maintenance to come and adjust the temperature, and place a sign stating caution hot water. First Aid kits were also observed in this area.

Food Service: LPA observed the facility kitchen pantry and refrigerator. The facility's amount of non-perishable and perishable food supply was sufficient for the amount of residents in care. Posted food menu listed a variety of options for residents to select from. Facility has a variety of food available for clients. Adequate amounts Dishes, cups, and utensils were also observed in proper storage. Emergency food and water were also observed stored in the attached garage. Sharp objects and cleaning supplies are kept secure and inaccessible to residents in care.

Signs: LPA observed the following posters: Infection Control, Long Term Care Ombudsman, Facility License, SEE/SAY Something, Resident Rights, Food Menu, Facility Sketch/Evacuation Plan.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. As one of the care staff reside within the facility.

Record Reviews: At 11:00 AM, LPA reviewed three (3) out of (3) Staff Files files which included current Health Screening, Personnel Records, Criminal Records Clearances, Background Statements and Fingerprinting, Annual Training.

LPA reviewed two (2) out of two (2) resident files for Admission Agreements, Updated Physician Reports, IPP annual report, and Needs and Services Plans. LPA observed 1 resident IPP plan was missing put the record did include the current quarterly report from IRC. IRC staff completed the IPP annual report and it is documented in resident file. Licensee is waiting for the final report to be provided.

Based on observations, One deficiencies will be cited per Title 22, California Code of Regulations, one technical advisory, and one technical violation. A copy of this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC9102TA, and appeal rights was read/reviewed with Licensee Rosario Nicolas.

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

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/01/2025 03:37 PM - It Cannot Be Edited


Created By: Lavette Farlow On 03/20/2025 at 01:07 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 HOME II
FACILITY NUMBER: 366408218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above in one area of the home by having a broken screen and boxes blocking the exit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee fixed the sliding glass door during the visit and agrees to remove the files and boxes by POC date.
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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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