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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606841
Report Date: 01/04/2024
Date Signed: 01/04/2024 12:16:32 PM


Document Has Been Signed on 01/04/2024 12:16 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SUNNYSIDE GUEST HOMEFACILITY NUMBER:
197606841
ADMINISTRATOR:RICHARD VILLAVERDEFACILITY TYPE:
740
ADDRESS:4457 N. MAXSON ROADTELEPHONE:
(626) 443-9529
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:12CENSUS: 12DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff Marissa BarajasTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Marissa Barajas and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Staff Marissa Barajas today 01/04/2024 at 10:20 AM and the following was observed:
Facility contains 7 Bedrooms and 3 Bathrooms, dining room, living room, TV room, and activity room.
Required Annual Inspection included Infection Control, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Rights- Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/ Incident Reports, Disaster Preparedness and Residents with Special Health Needs.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated.
Water temperature was checked in 3 resident bathrooms and measured between 105F. and !25 F.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Carbon monoxide detector was observed in the facility.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed for 5 residents and was given per physician's directions.
5 Resident Files and 5 Staff Files were reviewed.
Interviews were conducted with the 2 Staff on duty and 1 resident. 4 residents present at facility were non-verbal and unable to respond to questioning.
No deficiencies. Exit interview conducted and copy provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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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