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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032700845
Report Date: 07/11/2023
Date Signed: 07/11/2023 03:29:43 PM

Document Has Been Signed on 07/11/2023 03:29 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNRIDGE PLACEFACILITY NUMBER:
032700845
ADMINISTRATOR:SIX, ZULLYFACILITY TYPE:
735
ADDRESS:14124 LUPE ROADTELEPHONE:
(209) 296-5574
CITY:PINE GROVESTATE: CAZIP CODE:
95665
CAPACITY: 4CENSUS: 4DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Zully SixTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required visit. LPA met with Licensee/Administrator Zully Six and Licensee Paul Six.

The facility has 4 residents in care, all of which were at day program and at work at the time of the visit. One resident returned from day program later during the visit. LPA observed the physical plant to ensure compliance of Title 22 regulations. LPA inspected the common areas, kitchen, living room, bathrooms, bedrooms, and laundry room. The facility meets the food requirement of 7 days of non-perishables and 2 days of perishables.

The temperature inside the home was 76*F degrees. The hot water in the bathrooms were measured at 105.7*F. Bedrooms were observed to be clean and organized. Bathrooms were equipped with soap, paper towels, trash can, and handrails.

Emergency exits were clear from obstructions. The facility was observed to have a first aid kit, heating and central air conditioning, and a fire extinguisher. Medications, cleaning supplies, and sharps were locked away and inaccessible to residents in care.

LPA reviewed 4 resident files, all of which were up to date and had necessary documentation. LPA spoke to staff and 1 resident during the visit.

LPA requested the following documents: LIC 500, Surety Bond, and LIC 610D

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during this visit. An exit interview was held with Administrator Zully, and a copy of the report was given and left with Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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