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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320179
Report Date: 09/07/2022
Date Signed: 09/07/2022 12:54:00 PM


Document Has Been Signed on 09/07/2022 12:54 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 DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:SUNRISE OF BEVERLY HILLSFACILITY NUMBER:
198320179
ADMINISTRATOR:MALONE, JASONFACILITY TYPE:
740
ADDRESS:201 NORTH CRESCENT DRIVETELEPHONE:
(310) 274-4479
CITY:BEVERLY HILLSSTATE: CAZIP CODE:
90210
CAPACITY:127CENSUS: 72DATE:
09/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jason Malone TIME COMPLETED:
01:00 PM
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On 09/07/2022, Licensing Program Analyst (LPA) Troy Agard conducted a Case Management – incident visit and met with Jason Malone, Administrator and explained the purpose of the visit. The purpose of the visit is to follow-up on the incident that occurred today, 09/07/2022 which resulted in a fire occurring in one of the suites.

LPA Agard conducted an interview regarding the incident and the events leading up to it. LPA toured the facility to assess the damages. LPA requested a copy of the resident roster and the Emergency Disaster Plan. Documents were received at the time of visit. Servpro is onsite providing assessments, clean up services, air quality checks and air scrubbing. LPA reviewed facility’s emergency disaster plan. Based on the review of the plan, the facility followed their plan as described. The facility has vacant suites available in house and will have 8 residents relocated to the vacant suites.

LPA Agard advised that a subsequent visit regarding the incident may be conducted.



An exit interview was held, and a copy of this report was provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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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