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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320214
Report Date: 01/03/2024
Date Signed: 01/03/2024 11:52:47 AM


Document Has Been Signed on 01/03/2024 11:52 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:PACIFIC SUNRISE HOME 3FACILITY NUMBER:
198320214
ADMINISTRATOR:DANIEL, MONICA CENDANAFACILITY TYPE:
740
ADDRESS:28128 LOMO DRIVETELEPHONE:
(310) 938-6153
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 6DATE:
01/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Charesa Reyes/AdministratorTIME COMPLETED:
11:52 AM
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On 1/3/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Charesa Reyes/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. Facility has an approved hospice waiver for (3) patients, (5) non-ambulatory and (1) bedridden.

The facility is a single-story structure located in a residential neighborhood. It consists of (5) bedrooms, (3) full bathrooms, shaded back yard, front yard, laundry room and attached 2 car garage.


LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (5) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 109.7°F, Bathroom #1:107.7°F, Bathroom #2:105.4°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PACIFIC SUNRISE HOME 3
FACILITY NUMBER: 198320214
VISIT DATE: 01/03/2024
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files and (3) Medication Administration Records (MAR). First AID kit was checked. Last fire disaster drill was on: 11/16/2023.

LPA observed the facility's infection control practices. A copy of the liability insurance was provided to LPA during visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Charesa Reyes /Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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