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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804203
Report Date: 07/02/2024
Date Signed: 07/02/2024 12:17:10 PM

Document Has Been Signed on 07/02/2024 12:17 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:
07/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:14 AM
MET WITH:Roxana Galo M. (Applicant)TIME VISIT/
INSPECTION COMPLETED:
12:32 PM
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Licensing Program Analyst (LPA) Cuadra arrived announced to conduct a Pre-licensing Subsequent Facility Inspection and met with Applicant Roxana Galo. A pre-licensing inspection was completed on 06/21/2024.

During today’s visit LPA observed the following items:

* Applicant obtained 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 have chairs and dressers.
* Bedroom #2: have a regular bed in room.
* Bathroom located in bedroom #1 have non-skid mats placed in shower.
* Administration area have a designated locked cabinet that will be used for medication and file storage.
* Side deck area was cleaned.
* Fire Clearance clarification was obtained indicating that the premises is able to be occupied by six non-ambulatory residents. Applicant agreed that no bedridden residents could be accepted and any variation to the fire clearance needs to be notified to the Department to have the fire department re-inspected and approved for any bedridden residents prior to acceptance.
* Water heater is delivering temperature within 105-120 F degrees.

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with the process of license. Pre-Licensing items needed to be repaired have been resolved. Pre-Licensing is now complete.

No deficiencies cited at today’s inspection. Exit interview conducted with Applicant and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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