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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002108
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:55:59 AM


Document Has Been Signed on 12/08/2022 11:55 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SUNNY RIDGE MANOR HOMEFACILITY NUMBER:
306002108
ADMINISTRATOR:RUDY & FEMY SALVADORFACILITY TYPE:
740
ADDRESS:1201 POST ROADTELEPHONE:
(714) 526-7983
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 4DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Abelina BasaTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Lydia Martinez and Alvaro Ramirez, Jr. made an unannounced visit to conduct the required annual inspection. LPAs were screened for symptoms of Covid-19 and granted entry.

LPAs met with Caregiver Abelina Basa. LPAs explained the reason for the visit. At 10:05 a.m. LPAs and Caregiver toured the facility. The facility has 5 bedrooms, 2 bathrooms, living room, dining room, kitchen, laundry room and a two car attached garage. Facility has required Department postings including Valid License, Complaint Poster (PUB 475), Emergency Disaster Plan, Infection Control Plan and Personal Rights. LPAs observed the knives are kept locked in a kitchen drawer. The kitchen is clean and organized LPAs observed medications are kept locked in a kitchen cabinet. LPAs observed the facility to have approximately a two-day perishable and seven-day non-perishable supply of food for four residents in care. All resident rooms had required elements, including bed, chair, nightstand, closet space, and ample lighting. At 10:17 a.m. LPAs observed cameras in 3 resident bedrooms. LPAs and Caregiver toured the garage. The garage has a storage room that is used to store extra supplies. The garage is also used to store PPE, food and supplies. The garage is inaccessible to residents. At 10:21 a.m. LPAs observed a built-in bedroom in the garage with a bed and small refrigerator, and personal items. Clutter such as boxes, package of toilet paper on top of the bed. Caregiver stated no one sleeps in the garage. At 10:27 a.m. LPAs and Caregiver toured the back yard. The side exit gate on the garage side of the facility is operational. There is a covered patio with a seating area. No bodies of water observed. LPAs inspected the first aid kit. The first aid kit had all the required elements. Facility has a mitigation plan that has been approved.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Caregiver, a copy of this report was left at time of exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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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