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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600321
Report Date: 11/07/2024
Date Signed: 11/08/2024 09:02:10 AM

Document Has Been Signed on 11/08/2024 09:02 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 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: 44DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:ADMINISTRATOR JENNY ANGELESTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 11/07/2024, Community Care Licensee Division (CCLD) staff conducted an unannounced annual required visit using the CARE Inspection Tool Package for Sunnyside Retirement Center facility. CCLD staff met with Administrator Jenny Angeles. CCLD staff explained the purpose of today’s visit. The facility is licensed to serve forty-eight (48) ambulatory adults ages 18-59 years of age. Currently there is forty-four (44) residents that live at the facility.

The facility is a single-story commercial structure located in a commercial neighborhood. It consists of the following: twenty-four (24) residents’ bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, commercial kitchen, administrative offices, laundry, and outside patio area.

CCLD staff explained to Administrator Jenny Angeles, the purpose of the one-year Annual Inspection visit, and escorted CCLD staff on a tour of the entire inside and outside facility grounds. As part of the inspection, CCLD staff reviewed: five (5) residents service records, five (5) residents medication records, five (5) staff records. CCLD staff interviewed five (5) residents and five (5) staff members for visit. The facilities’ last fire drill was conducted on 09/14/2024. No weapons were found or stored in the premises. Commercial kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is located in the kitchen storage area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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: 11/07/2024
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CCLD staff observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. CCLD staff observed the following during inspection of resident’s rooms #104, #107, #116, #118, #123, #125, #127: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, CCLD staff observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. CCLD staff observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 109 degrees Fahrenheit, bathroom #2 hot water temperature properly measured at 108 degrees Fahrenheit, bathroom #3 hot water temperature properly measured at 107 degrees Fahrenheit, bathroom #4 hot water temperature properly measured at 109 degrees Fahrenheit, bathroom #5 hot water temperature properly measured at 109 degrees Fahrenheit, bathroom #6 hot water temperature properly measured at 108 degrees Fahrenheit, bathroom #7 hot water temperature properly measured at 110 degrees Fahrenheit, and Commercial Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility thirty-six (36) Carbon Monoxide and thirty-six (36) Smoke Detectors hard wired operated and were tested and are working properly. The facility seven (7) Fire extinguishers was checked and found to be fully charged and accessible. Fire extinguishers last inspected by fire department on 06/14/2024. Fire clearance granted on 03/15/2024. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility two (2) first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Five (5) resident files were reviewed and found to be complete. CCLD staff reviewed five (5) resident medications and they were all found to be administered according to doctor's orders. Five (5) staff files were checked and have the required documents. CCLD staff noted the Administrator Jenny Angeles Certification # 6020687735 expiration date of 11/15/2024 was valid at time of visit. The facility does not handle residents money/cash resources and no Surety bond is needed. General Liability Policy #7039533665 policy period from 07/01/2024 to 07/01/2025 underwritten by Columbia Casually Insurance Company, coverage 1,000,000/5,000,000 is valid at time of inspection. Administrator Jenny Angeles to email CCLD staff a full copy of the commercial insurance policy including all endorsements no later than 11/25/2024. All the required documents are posted in the facility in a clearly visible area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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: 11/07/2024
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), CCLD staff did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is due. $25.00 is due on 11/15/2024. PIN 153727. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Jenny Angeles.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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