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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602882
Report Date: 08/30/2021
Date Signed: 08/31/2021 08:52:11 AM

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 OF CLAREMONTFACILITY NUMBER:
198602882
ADMINISTRATOR:MENSAH, ERICFACILITY TYPE:
740
ADDRESS:2053 N TOWNE AVETELEPHONE:
(909) 398-4688
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:81CENSUS: 57DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Covering Director-Kimberly Sanchez TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Kimberly Sanchez (Director of Sunrise San Marino-currently covering for Facility Director for this location) and explained the purpose of today's visit
This is an RCFE with a capacity of 81.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, in all common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • A majority of Residents have their own private room.
  • Per Director, the majority of Residents are fully vaccinated.
  • Per Director, all current staff are fully vaccinated.
  • 30 day supply of medication reviewed for (6) residents (Resident #1 through Resident #16)
  • PPE supplies observed.
  • Incontinence supplies observed.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Residents were socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Director
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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