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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601661
Report Date: 11/17/2021
Date Signed: 11/17/2021 03:08:56 PM

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 PLAYA VISTAFACILITY NUMBER:
198601661
ADMINISTRATOR:SHANNON HOWELLFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRTELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:102CENSUS: DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shannon HowellTIME COMPLETED:
03:04 PM
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Licensing Program Analysts (LPAs) Ngozi Nwaokoro conducted an unannounced visit to Sunrise of Playa Vista. The purpose of today’s visit was to conduct the annual inspection and to observe the infection control practices. LPA met Shannon Howell. Facility is licensed for 102 ambulatory and non-ambulatory residents of which 7 are non-ambulatory. Currently, their census is 67 residents.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Seven rooms were inspected. The fire drill was last conducted on 10/30/21. The facility has 6 floors which consist of resident bedrooms, bathrooms, living room, activity room, dining room, and kitchen. Floors 3 and 4 are used for memory care. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked, bathrooms were found to be within Title 22 regulations and were clean and operational. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 105-120 degrees on floor 1-6 floor. Resident bath towels were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available. There is fire extinguisher fully charged in all the floors and the kitchen. Smoke detectors and carbon monoxide were operable. A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate. first aid kit with manual was checked and in order.

No deficiencies were cited during this inspection visit.

Exit interview conducted and a copy of the report was given to Shannon Howell, the Administrator.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Ngozi NwaokoroTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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