197610213-11-18-2021-31-AS-SSTS-C8VUU8-20211118145308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610213
Report Date: 11/18/2021
Date Signed: 11/18/2021 02:54:03 PM

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:	SUNRISE COMFORT		FACILITY NUMBER:	197610213
ADMINISTRATOR:	OCHOA, MIRANDA		FACILITY TYPE:	735
ADDRESS:	45568 RODIN AVE		TELEPHONE:	(310) 920-4666
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	4	CENSUS: 0	DATE:	11/18/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Dominic Anderson, Administrator/Applicant		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Shira Stamps met with Dominic Anderson(Licensee/Applicant) and Miranda Ochoa (Administrator) for a Pre-licensing inspection at 12:50 pm.

Entrance interview conducted.

The home will be vendored by North Los Angeles Regional Center. The home will serve four (4) level 4 intellectually disabled adults. Clients will be all ambulatory. The facility has four (4) bedrooms and two (2) bathrooms designated for a capacity of four (4) clients. There is no bedroom designated for staff. Staff will be awake at night.

The physical plant was toured inside and out at 12:55 pm.

Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 64 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises.

The smoke alarm and carbon monoxide detector were operational and tested at 1:15 pm. The fire extinguisher appear to be full and serviced on 09/09/2021.

Resident rooms: Rooms available are all private. LPA observed rooms to have bedding sheets, pillowcase, blankets, mattress pads, which are in good condition. There is at least one chair, a night stand, and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition.

Window covering and window screens are in good repair for each room.

Consumers will have sufficient amounts of supplies for personal hygiene products, which is provided by the Licensee. Continued...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

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: SUNRISE COMFORT	FACILITY NUMBER: 197610213
	VISIT DATE: 11/18/2021

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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 was unable to be measured, due to the gas not turned on. The Licensee with provide verification by the due date. The Licensee will provide appropriate non-skid mat in each shower. Trash cans needed in each restroom with lids to protect consumers from cross contamination. Towels and washcloths will not be shared.

Kitchen Area: LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and cleaning supplies will be kept locked inaccessible in the hallway cabinet.

Medications will be kept centrally stored and locked in a cabinet located in the hallway. Stove and refrigerator are clean and in good operation. LPA observed sufficient supply of 7 day non-perishable foods.

Outside: LPA toured the outside area. LPA observed a covered shaded area for clients. No bodies of water.

Garage: The garage is accessed from outside. It is maintained locked inaccessible to clients.

Files will be kept confidentially stored in the closet adjacent to the kitchen and supplied to licensing staff upon request.

LPA discussed preplacement, staffing, training, customer service, inspection authority, reporting requirements(mandated reporter), records, citations, criminal record clearance, civil penalties, labor law, activities, expectation is to follow all rules and regulations.

Applicant/ Administrator has completed component III.

The licensee will need to complete the following before the license is approved.

1. Trash cans with lids in the two (2) bathrooms to protect from cross contamination. Trash cans with lids in four(4) bedrooms. Submit receipt for the trash can.

2. Two(2) non-slip mats for each bathroom. Submit receipt.

3. Fix hanging wire located outside. Submit a photo.

Continued...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

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: SUNRISE COMFORT	FACILITY NUMBER: 197610213
	VISIT DATE: 11/18/2021

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The licensee will need to complete the following before the license is approved. CONTINUED...

4. Hot water unable to be measured. Once gas is turned on; do a hot water temperature log; test the water. Submit the log by Thursday 12/02/2021.

5. Turn on gas. Submit receipts/verification

6. Create five(5) Covid symptom screening questions. Submit questions via email/text.

7. Purchase a thermometer. Submit receipt.

8. Install shower head for Bedroom #4. Submit picture.

9. Notify LPA when land line is turned on. LPA will call the facility number to verify it is working.

The facility is ready for operation upon correction of requested items in this report, and final approval of the application. Submit items for correction no later Thursday 12/02/2021.

Exit interview conducted and report was delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC809 (FAS) - (06/04)

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