198320214-11-10-2021-11-AS-JCAN-C8MMDU-20211110083143

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320214
Report Date: 11/08/2021
Date Signed: 11/10/2021 08:31:54 AM

Document Has Been Signed on 11/10/2021 08:31 AM - 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:	PACIFIC SUNRISE HOME 3		FACILITY NUMBER:	198320214
ADMINISTRATOR:	DANIEL, MONICA CENDANA		FACILITY TYPE:	740
ADDRESS:	28128 LOMO DRIVE		TELEPHONE:	(310) 938-6153
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY: 6		CENSUS: 3	DATE:	11/08/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	LICENSEE MONICA DANIEL		TIME COMPLETED:	11:00 AM

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	On 11/08/2021 Licensing Program Analysts (LPA) Jose Calderon conducted an announced face to face visit to the facility for purpose of a pre-licensing evaluation. The requested capacity is for 5 ambulatory Adult Resident and one bedridden resident Facility (ages 18 through 59). Facility is a 5 bedroom, 3 bathrooms, single-story house with attached garage. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a covered patio for shade. The patio contained 1 small table and 6 chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents Bedrooms: All 5 Bedrooms are for ambulatory clients. Bedroom’s #1, #2, #3 and #4 have one bed each and #5 has two beds. There is one dresser with drawers in Bedrooms #1 -#5 which comply with the requirement of 8 cubic feet of space. 3 Bathrooms: Have a working toilet, wash basins, and Full shower. LPA observed adequate lighting in hallway leading to bathrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC SUNRISE HOME 3	FACILITY NUMBER: 198320214
	VISIT DATE: 11/08/2021

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu: The telephone system is a land line and operable. Emergency Disaster Plan and "See something, say something Let Us Know" were missing. Fire Extinguisher 1 mounted on the wall in hallway next to the kitchen.
Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet located in the kitchen area. Food supply is adequate; stored in kitchen refrigerator and cabinets and consists of the following: A variety of Fresh and Canned fruit, vegetable and meat food items. Smoke Detectors: 7 hard wired operated & working. Carbon monoxide detector located and mounted in the hallway is operational. Appliances: Gas Stove, oven, microwave, washer, and dryer working. There are 2 refrigerators, 1 the home and garage. Refrigerator in the kitchen has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in the storage room located in the kitchen. Water Temperature: Bathrooms water temperature tested in #1 at 85 F. and #2 86 F. degrees. Medications, First-Aid Kit & Book: Medication administration records storage area, and first aid kit has been inspected, which are stored in locked kitchen cabinet adjacent the refrigerator, available for staff use but inaccessible to clients.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC SUNRISE HOME 3	FACILITY NUMBER: 198320214
	VISIT DATE: 11/08/2021

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Clients & Staff Files: Records of staff and clients shall be stored in a locked in staff closet and the section has been inspected.
Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. LPA did not observe any pet or bodies of water at the facility. LPAs did not observe delayed egress, chain locks or dead bolts on exits. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Pool/Jacuzzi & Pets: LPA did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 7/21/2021 for 5 ambulatory clients and one client bedridden. LPA did not observe delayed egress, chain locks or dead bolts on exits. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

Component III: (11/08/2021) about how to operate the facility within substantial compliance.

During the pre-licensing inspection licensee to review Component III and email LPA Calderon when done.

An exit interview was conducted, and a copy of this report has been furnished to the applicant via email. Accordingly, LPA Jose Calderon will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC809 (FAS) - (06/04)

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