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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600321
Report Date: 08/12/2024
Date Signed: 08/12/2024 03:34:04 PM

Document Has Been Signed on 08/12/2024 03:34 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SUNNYSIDE RETIREMENT CENTERFACILITY NUMBER:
198600321
ADMINISTRATOR/
DIRECTOR:		ANGELES, JENNYLYNFACILITY TYPE:
735
ADDRESS:22713 SOUTH VERMONT AVENUETELEPHONE:
(310) 320-3318
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 48CENSUS: DATE:
08/12/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Licensee Representative Ben Lyons, Licensee Representative Taylor Richardson, Facility Legal Consultant Joel Goldman TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 08/12/2024 at 2:00 PM, a Virtual Meeting was held by the El Segundo Adult and Senior Care Regional Office via TEAMS (video conferencing). Present during this meeting were Regional Program Manager Benita Yates, Licensing Program Manager Ulysses Coronel, Licensing Program Analyst Hollie Enriquez, Licensee Representative Ben Lyons, Licensee Representative Taylor Richardson, Facility Legal Consultant Joel Goldman

Virtual Meeting to discuss Request for a capacity increase submitted via email on 8/9/24 and Title 22 Regulation Section 80008 Licensing of Integral Facilities. Regional Manager Yates requested clarification regarding Corporate Structure and incomplete documents submitted for the request to increase capacity. The following documents were requested:

(continued on 809-C)
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SUNNYSIDE RETIREMENT CENTER
FACILITY NUMBER: 198600321
VISIT DATE: 08/12/2024
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·Revised LIC 200 - Application For A Community Care Facility (include both
addresses, authorized signatures)
· Updated LIC 308 - Designation of Facility Responsibility
· Updated LIC 309 - Administrative Organization
· Updated LIC 400 – Affidavit Regarding Client Cash Resources
· Updated LIC 610 for (both addresses) – Emergency Disaster Plan
· Updated LIC 999 for (both addresses) – Facility Sketch/ Floor plan
· Board Resolution authorizing the request to increase capacity, designee(s) to
submit application.
· Control of Property for both addresses listed on LIC 200
· Surety Bond
· $25.00 application fee
· Updated Plan of Operation

No deficiencies were cited during this meeting.

A copy of report was emailed to Administrator for signature.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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