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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002176
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:35:25 PM


Document Has Been Signed on 03/25/2022 12:35 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SUNNY HILLS VILLA ELDER CARE HOMEFACILITY NUMBER:
306002176
ADMINISTRATOR:DELIA GOGFACILITY TYPE:
740
ADDRESS:25121 BAUTISTA DRIVETELEPHONE:
(949) 351-2984
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Delia GogTIME COMPLETED:
01:00 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) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver. LPA met with Delia Gog, Administrator and explained the nature of the visit.

LPA accompanied by Administrator began the tour of the inside and outside of the facility. There are six residents in care and there is no active Covid-19 case in the facility. LPA observed a check in station in the main entry of the facility. LPA observed residents in their bedrooms. All residents appeared to be clean and well taken care of. LPA observed required Department postings, Covid-19 precautionary postings, and hand washing signs in the facility. All restrooms observed to have supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed the emergency food supply, water supply and PPE supply in the attached garage. LPA toured the outside of the facility and observed various shaded seating area for residents’ enjoyment. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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 1