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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002108
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:34:32 PM

Document Has Been Signed on 03/11/2025 04:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SUNNY RIDGE MANOR HOMEFACILITY NUMBER:
306002108
ADMINISTRATOR/
DIRECTOR:		RUDY & FEMY SALVADORFACILITY TYPE:
740
ADDRESS:1201 POST ROADTELEPHONE:
(714) 526-7983
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 5DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Shirley VillarminoTIME VISIT/
INSPECTION COMPLETED:
04:49 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Shirley Villarmino was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Shirley Villarmino has a valid Administrator certificate which expires on February 14, 2027.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for six. The facility is a one story home with four resident bedrooms, two of which are shared, one staff bedroom, two shared resident bathrooms, a living room, a family room, a dining room, a kitchen, and an attached two car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care, four of which are on hospice, and two care giving staff present. LPA observed residents relaxing in the family room and in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall in the living room. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens to be stored in a hallway cabinet. LPA inspected the two shared resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 107 and 112.1 degrees Fahrenheit. LPA observed the staff bedroom to be locked and inaccessible to residents in care.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The five top electric stove was operational. LPA observed knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUNNY RIDGE MANOR HOME
FACILITY NUMBER: 306002108
VISIT DATE: 03/11/2025
NARRATIVE
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A fire extinguishers is located in the kitchen and it was observed to be charged and last serviced on September 11, 2023. LPA tested the individual smoke detectors which tested operational. LPA tested the individual carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on February 6, 2025. The centrally stored medication is kept in a locked cabinet in the kitchen. A First Aid kit was observed be stored in the resident hallway and it had all the required components. LPA observed a fire place in the living room and it was observed to not be in operation at the time of visit. The door leading to the attached two car garage is kept locked and inaccessible to residents in care. The garage is used for storage. LPA observed chemicals and toxins to be stored in the locked two car garage. LPA observed additional linens and blankets to be stored in the garage. LPA observed the facility has a three day emergency food and water supply to be stored in the garage.

LPA and the AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on the north side and south side of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all five resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed all five residents’ medication and medication records. LPA reviewed two staff files. LPA observed that Staff #2 did not complete the required annual training for the year of 2024. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Shirley Villarmino. A copy of the report and Appeal rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/11/2025 04:34 PM - It Cannot Be Edited


Created By: Brandon Lopez On 03/11/2025 at 03:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY RIDGE MANOR HOME
FACILITY NUMBER: 306002108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health and safety risk to persons in care. During a tour of the physical plant, LPA observed the only facility fire extinguisher mounted in the kitchen to be charged and last serviced on September 11, 2023.
POC Due Date: 03/25/2025
Plan of Correction
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AD agreed to either service the fire extinguisher or buy a new fire extinguisher for the facility. AD agreed to submit either proof of maintenance of the fire extinguisher or proof of purchase to LPA via email or fax by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/11/2025 04:34 PM - It Cannot Be Edited


Created By: Brandon Lopez On 03/11/2025 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY RIDGE MANOR HOME
FACILITY NUMBER: 306002108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During staff file review, LPA observed that Staff #2 (S2) did not complete the required annual training for the year of 2024.
POC Due Date: 04/01/2025
Plan of Correction
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AD agreed to have Staff #2 complete the required annual training. AD agreed to submit proof of training completion to LPA via email or fax by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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