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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408218
Report Date: 03/16/2026
Date Signed: 03/16/2026 05:42:31 PM

Document Has Been Signed on 03/16/2026 05:42 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: 4DATE:
03/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:58 PM
MET WITH:Lourdes Albao, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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On 03/16/2026, at 2:58 PM, Licensing Program Analyst, (LPA) LaVette FArlow, (LPA) arrived at the Sunshine Home II, unannounced to conduct the Annual Inspection. LPA was greeted and granted entry by Caregiver Larnie Cunanan. Caregiver Larnie contacted Licensee Rosario Nicolas to notify of LPA arrival. Rosario requested to speak with LPA Farlow and inform LPA that the Administrator would assisted LPA with any questions or concerns.

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

Physical Plant: At 3:15 PM, LPA conducted a tour of the facility. 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 4. Resident were all present at the time of the visit. 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 78 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 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 3, 2026. Backyard provides sufficient space, shady and adequate seating. Pathways free of clutter and obstruction. The facility has two exit doors leading to the backyard. 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: 03/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2026
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUNSHINE HOME II
FACILITY NUMBER: 366408218
VISIT DATE: 03/16/2026
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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 105.3, and 105.0. LPA advised staff to monitor the water temperature. First Aid kits were also observed in this area and complete.

Food Service: LPA observed the facility kitchen pantry and refrigerator. The facility's maintains a sufficient amount of non-perishable and perishable food supply for the number 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.

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 3:45 PM, LPA reviewed three (3) out of (3) Staff Files. The files included current Health Screening, Personnel Records, Criminal Records Clearances, Background Statements and Fingerprinting, Annual Training. All staff records we available for review and appears to be maintained.

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 that residents file appeared to be maintained. LPA conducted a medication audit and observed that 1 out of 2 residents MARs was missing staff initial stating that medication had been issued for today. A Deficiency cited.

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. LPA observed that the Licensee did not review and update the Emergency Disaster Plan LIC610E. A Technical violation issued.



Based on observations, One deficiencies and one technical violation will be cited per Title 22, California Code of Regulations. A copy of this report LIC809, LIC809C, and LIC809D, and appeal rights was read/reviewed with Administrator Lourdes Albao.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/16/2026 05:42 PM - It Cannot Be Edited


Created By: Lavette Farlow On 03/16/2026 at 05:07 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: 03/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.

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 1 out of 2 residents. LPA observed that 1 out of 2 residents MARs were missing staff initials indicating the medication had been dispensed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2026
Plan of Correction
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Administrator agrees to have all staff complete a training regarding medication and common medication errors by POC due date. All staff will submit a statement of understanding acknowledging the regulation cited and understanding of the regulation. This will be submitted to LPA via email or mail by POC due 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2026


LIC809 (FAS) - (06/04)
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