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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804203
Report Date: 06/21/2024
Date Signed: 06/21/2024 03:07:11 PM

Document Has Been Signed on 06/21/2024 03:07 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SUNSHINE PETALUMA CARE HOMEFACILITY NUMBER:
496804203
ADMINISTRATOR/
DIRECTOR:		CUEVAS, ELIAFACILITY TYPE:
740
ADDRESS:804 ELY SOUTH BLVDTELEPHONE:
(707) 364-7247
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 0DATE:
06/21/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:31 PM
MET WITH:Roxana Galo M. (Applicant)TIME VISIT/
INSPECTION COMPLETED:
03:22 PM
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Licensing Program Analyst (LPA) Cuadra arrived announced to conduct a pre-licensing inspection and was greeted by Applicant, Roxana Galo. Facility currently does not have residents in care. Once obtained, applicant will submit proof of required liability insurance. Facility has a Dementia Care Program. Per Applicant, they have submitted to the Application Unit a request for a hospice waiver for two residents, which is currently under review.

The facility consists of a single story residence with a total of 3 bedrooms, 2 full bathrooms, administration office, laundry room located in the garage, kitchen, dining room, and living room as common areas. The facility received a fire clearance approval on 1/31/2024 by the Petaluma Fire Department for six [6] non-ambulatory residents in rooms# 1-3. According to applicant, the Fire Inspector mentioned that there are some rooms that could be used as a double room occupancy or bedridden residents. However, fire clearance effective 1/31/2024 did not clarify specific information on double room or bedridden capacity approval or which rooms are approved for bedridden use. LPA have notified analyst in the application unit and applicant to contact Fire Inspector to revise the fire clearance approval to clarify if one room could be used as a double room, bedridden capacity could be approved and which bedrooms could be approved for double room and bedridden.

Two [2] fire extinguishers present and last serviced on August, 2023. Facility has a fire pull system. First aid kit present with all required items. Night lights in hallway present. Smoke and carbon monoxide detectors present and functioning. Working auditory alarms are placed on all exits. Administrator Certificate for administrator Celia Cuevas # 6057784740 expires 1/4/2025.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SUNSHINE PETALUMA CARE HOME
FACILITY NUMBER: 496804203
VISIT DATE: 06/21/2024
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Continued from LIC809...

At approximately 1:00pm LPA/Applicant toured the building and grounds. The facility was found to be at a comfortable temperature. Bedroom #2 needs a regular bed instead of half rail bed currently in room. All resident rooms #1-3 needs additional furniture as stated per regulation with a chairs. Cleaning supplies will be stored in a secured cabinet located in the garage. Administration area located adjacent to the kitchen needs locked cabinet that will be used for medication and file storage. Side decks has debris that needs to be removed. Water temperatures read at: 90.5 and 88.9 degrees F which needs to be adjusted to 105-120 F degrees as stated per regulation. All bathrooms skid mats available need to be placed in shower.

Items required to be repaired/addressed before licensure:

* Applicant needs to obtain all required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils.
* Bedroom #1, #2 and #3 needs chair and dresser.
* Bedroom #2: needs a regular bed instead of half rail bed currently in room.
* Bathroom located in bedroom #1 needs non-skid mats available need to be placed in shower.
* Administration area needs locked cabinet that will be used for medication and file storage.
* Side deck area has debris that needs to be removed.
* Fire Clearance clarification regarding double room occupancy and possible bedridden status.
* Water heater needs to be adjusted to deliver temperature of 105-120 F degrees.

Applicant agreed to notify Community Care Licensing once all repairs and personal accommodations are completed. LPA will conduct a subsequent visit to confirm required repairs had been completed. LPA will notify CAB analyst. LPA/Applicant reviewed and completed Component III orientation.

Exit interview conducted with Applicant and a copy of this report given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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