J and G Sunshine Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced annual required visit and inspection of the facility. Upon arrival LPA met with John Lingad and explained the reason for the visit. LPA spoke with Administrator - Josefina Lacsamana over the telephone. At approximately 12:10pm Administrator came to the facility and met LPA. The facility is licensed to serve six (6) non-ambulatory residents with an approved waiver for three (3) hospice residents and one (1) bedridden resident. At 10:45am, with the assistance of Staff, LPA took a tour of the physical plant. The facility is a one story structure with six (6) bedrooms, three (3) bathrooms, kitchen, dining area, living room and office area. Required postings were observed in the entry area. The smoke alarms/carbon monoxide detectors are battery operated. At 11:15 am smoke/carbon monoxide detectors were tested and observed to be functional. There are four fire extinguishers, located in the kitchen, dining room, living room and in the hallway next to bedroom #5. All fire extinguishers were observed to be full and serviced together on 1/23/2025. The auditory alarms on all exit doors were functional at the time of the visit. Facility conducts quarterly fire and earthquake drills. The last fire drill was conducted on 06/15/2025 and earthquake drill was conduced on 08/15/2025. Common Areas: These included the living room and dining room. The common areas were properly furnished with tables and chairs for the number of residents. A piano and keyboard were seen in the dining room and a television and cabinets with games, karaoke machine in the living room. There is a linen closet in the hallway, near the bedrooms. Laundry Room: The laundry room is accessed through a locked door from the living room. LPA observed chemicals and detergents stored in cabinets, in the locked laundry room. Continued on 809-C Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient supply of perishable (2 days) and non-perishable (7 days) foods at the facility. Knives were stored in a locked drawer in a kitchen cabinet. Kitchen chemicals and detergents are stored in the locked laundry room. The kitchen has a eating area with table and office area, on one side and has 2 exit doors. Bedrooms: There are total of six (6) bedrooms. Bedrooms #1-5 are designated for residents' use and bedroom #6 is used for staff use/live-in staff room. All bedrooms are properly furnished with appropriate beddings, chairs, cabinets, linens and have sufficient lighting. Bathrooms: There are three (3) bathrooms, two (2) of which are designated for residents' use and one (1) for staff. LPA observed functional fixtures, grab bars and non-skid mats in each bathroom. Hot water temperature at resident bathrooms was measured at 115.6 and 120.5 degrees Fahrenheit. Surrounding Grounds: There were no bodies of water or obstructions on the premises. There is a covered patio with furniture appropriate for outdoor use. Facility does not use the front entry door, the entrance is from the front, side gate, leading to the living room. There are two exits doors in the kitchen, there are exits in the living room, dining room and in all the bedrooms. Facility uses the front side gate as the main emergency exit door. There is a detached garage, currently used as storage. LPA observed two refrigerators and cabinets for emergency food in the garage. LPA observed a milk carton with expiration date of 09/01/2025 and several expired cans in the cabinets. Administrator immediately destroyed and trashed the expired items; a citation will be provided. Resident Files/Medications: Files for all six residents were reviewed for completion of required documents. Medications for three out of six residents were counted for accuracy of administration based on physician orders. LPA observed a complete first aid kit and the manual in the locked medication cabinet. Staff Files: LPA also conducted a file review of 5 staff records to insure forms and training are up to date and in compliance with licensing requirements and staff have been cleared and associated with the facility. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was observed during the visit and citation and appeal rights provided. Exit Interview conducted / A Copy of the Report Issued to the Administrator.the state’s words, verbatim · CDSS document, Sep 11, 2025

Type of visit: Prelicensing

On 9/9/2024 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the facility Administrator Josefina Lacsamana. This is a Change of Ownership Application from facility #197602144 to #197610533 to operate a Residential Care Facility for Elderly (RCFE). A Change in Ownership (CHOW) Application to operate a RCFE was received by Community Care Licensing (CCL) on November 30th, 2023. A fire clearance was approved on December 29th, 2023, for five (5) Non-ambulatory and one (1) Bedridden residents for a total capacity of six (6). The smoke alarms and carbon monoxide detectors are hard wired and inter-connected, they were tested and are operational. The facility has four fire extinguishers that were purchased on 1/8/2024 and are located in the common areas. A tour of the physical plant was initiated at approximately 10:30am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, dining ware to accommodate a maximum capacity of six (6) residents. Knives and other sharps were observed locked in the cabinet next to the kitchen area. BEDROOMS: The facility has six (6) bedrooms, of which five (5) bedrooms are designated for residents' use and one (1) bedroom for staff use. The applicant furnished all clients' bedrooms with beds, night stands, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. BATHROOMS: The facility has four (4) bathrooms, of which three (3) are designated for residents' use, and one (1) is for staff use only. Bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids. The hot water delivered in the bathrooms measured at 10:50am to be at 113.8 degrees. Continue on LIC809-C COMMON AREAS: These included living room and a dining room. The living room was equipped with furniture, a television, tables and chairs. There is no fireplace in the facility. The dining area has a dining room table to accommodate six (6) residents, buffet, a sofa and a piano. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 10:45am to be 68 degrees. GARAGE: The garage is used as extra storage for non-perishable, emergency food supplies and water. There is another freezer/refrigerator in the garage for additional food items. LPA observed additional laundry detergents along with other chemicals are also stored in the garage. LAUNDRY ROOM: The washer and dryer is located in a separate locked area next to the living room, laundry chemicals are also kept in the laundry area which is always locked and under supervision. MEDICATIONS: The medications are kept locked in a cabinet located in the office area which is next to the kitchen. At approximately 12:00pm to 1:00pm LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. All medications are properly labeled and checked for expiration dates. First Aid and the new manual is also locked in the cabinet. LPA observed the First-aid has all proper items and is current. Resident Files: From 11am to 12pm LPA conducted a file review of all client records to ensure compliance of licensing forms. Resident files are complete and kept locked in cabinet, in the hallway. Staff Files: Staff files are also kept in a locked cabinet in the hallway area. From 1:00pm to 1:45pm LPA conducted staff file review, files were complete with all documents and training certificates. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) residents. There is no body of water. In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised. Exit interview conducted and copy of this report signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, Sep 9, 2024

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 Method: Telephone call with CAB COMP II Participants: Josefina Lacsamana, Administrator/Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jun 28, 2024