197609684-3-18-2022-31-AS-MCAA-CCMTHP-20220318144503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609684
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:45:48 PM

Document Has Been Signed on 03/18/2022 02:45 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SUNNYBRAE HOME		FACILITY NUMBER:	197609684
ADMINISTRATOR:	SAVELLA, JEFFREY		FACILITY TYPE:	740
ADDRESS:	8001 SUNNYBRAE AVE		TELEPHONE:	(323) 455-7821
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 6	DATE:	03/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Josephine Espiritu		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Michael Cava. LPA met with the administrator, Josephine Espiritu and stated the purpose of the visit. LPA observed that all six (6) residents were at the facility during the visit. The tour of the physical plant was conducted at 11:45am and the following were noted: The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear a mask and must be screened. The screening area is located near the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened by staff upon entry. All staff were observed to be wearing a mask. The facility submitted an approved Mitigation Plan. Signs to wear a mask and other COVID 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with covers. The facility has a designated visitor's area at the backyard. The facility has a sufficient supply of PPE in the storage room. Resident rooms: LPA toured 5 resident rooms. All 5 out of 5 rooms meet regulation. LPA observed rooms to have appropriate bedding sheets, pillowcase, mattress pad, and blanket which are in good condition. There is at least one chair, night stand and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition. Facility has one room designated for staff.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNNYBRAE HOME	FACILITY NUMBER: 197609684
	VISIT DATE: 03/18/2022

NARRATIVE

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Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 105 degrees F. LPA observed appropriate grab bars and non-skid mat in each bathroom. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene items which is provided by the Licensee.

Common Areas: LPA toured all common areas of the facility. LPA observed common areas to be clean and furniture in good repair. The facility maintains a comfortable temperature at 76 degrees F. LPA observed 2 fire extinguishers. One at the kitchen and one in the living room. Last service date was 3/24/2021. The smoke/carbon monoxide detectors are operational. Both are battery operated. There are no issues with Fire Clearance.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water. There are two storage areas observed to be locked and inaccessible to the clients.

The garage: There is no attached garage to the home.

Food Inspection: LPA conducted a food inspection tour. LPA observed there to be sufficient stock of two- day perishable and seven-day non-perishables foods. Snacks and beverages are available for clients in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides or toxins were stored and locked away separately .

Laundry/Linen: The laundry area is inaccessible to the clients. There is enough linen available to change weekly or more if need.

Pursuant to CA code of Regulations Title 22 or Health and Safety Code. No deficiencies observed during the day's visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC809 (FAS) - (06/04)

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