<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601662
Report Date: 11/08/2022
Date Signed: 11/08/2022 04:45:35 PM


Document Has Been Signed on 11/08/2022 04:45 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SUNRISE ASSISTED LIVING AT SAN MARINOFACILITY NUMBER:
198601662
ADMINISTRATOR:KIMBERLY SANCHEZFACILITY TYPE:
740
ADDRESS:83332 HUNTINGON DRTELEPHONE:
(626) 292-7800
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:74CENSUS: 51DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Liberty Adalla, Resident Care DirectorTIME COMPLETED:
04:50 PM
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
Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Resident Care Director Liberty Adalla. The purpose fof the visit was explained telephonically to Administrator Kimberly Sanchez. The facility is a 2 story building licensed for 74 adults 60 and over, approved for 74 non-ambulatory, of which 10 may be bedridden. The facility has a hospice waiver and approved delayed egress. The last fire emergency drill was conducted on 10/28/2022. The alarm system was tested on 10/22/2022, and a Fire Inspection was completed on 4/6/2022.

OBSERVATIONS

Infection Control:

  • Visitors are screened in the concierge area. An electronic sign-in system, contact-less thermometer, and hand sanitizer is in place. Hand sanitizer stations were observed in common areas. Residents are encouraged to wear masks.
  • COVID-19 Infection Control Practices and signs were not observed in the main entrance, post areas, and public restrooms. The facility walls are currently being renovated. The estimated project completion is early December 2022. An Infection Control Plan & Monkey Pox Plan were submitted on 8/16/2022.
  • Adequate supply of Personal Protective Equipment (PPE's) was observed. The facility has a contingency plan for back-up staffing if needed.

Medications:
  • Ten (10) centrally stored resident medication records were reviewed.

*See LIC 809C for report continuation.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SUNRISE ASSISTED LIVING AT SAN MARINO
FACILITY NUMBER: 198601662
VISIT DATE: 11/08/2022
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
26
27
28
29
30
31
32
Physical Plant:
  • The facility consists of a Memory Care unit "Reminiscence", 52 resident rooms, 2 activity rooms, 2 dining rooms, kitchen, 2 tv rooms, library, Bistro room, hair salon, administration offices, laundry rooms, storage areas, 2nd floor terrace area, 1st and 2nd floor stairways evacuation chairs, and parking garage.
  • Sixteen (16) rooms were inspected rooms were inspected.

Food Service:
  • Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, 7-day non-perishables, and emergency food supplies.

Resident Files:
  • Medication Administration Reports were reviewed.
  • Fourteen (14) residents are enrolled in hospice.


Staff Files:
  • Criminal Background Clearance was checked.


Liability Insurance:
  • Proof of liability insurance was provided.


Exit interview was conducted with Resident Care Director Liberty Adalla. A copy of the report was issued..
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2