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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002344
Report Date: 07/29/2024
Date Signed: 07/29/2024 10:10:02 AM


Document Has Been Signed on 07/29/2024 10:10 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SUNNY SLOPES AT ST. AGNES HOME IIFACILITY NUMBER:
306002344
ADMINISTRATOR:INES OTBOFACILITY TYPE:
740
ADDRESS:1081 CONCORD WAYTELEPHONE:
(562) 905-0836
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 5DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Ines OtboTIME COMPLETED:
10:15 AM
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On 7/29/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Caregiver, Abigail Ortiz who was informed of the purpose of the visit. Administrator, Ines Otbo arrived during the visit and was also informed of the purpose of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for five (5), and LPA was informed there are currently two (2) residents receiving hospice services at the facility.

LPA toured the facility with Business Manager (BM), Michelle Otbo and observed the facility is made up of a two-story home with four (4) resident bedrooms, two (2) bathrooms, two (2) staff rooms, a kitchen, dining room, living room, and attached garage. During the tour, BM Otbo tested one (1) of the smoke alarm/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. No bodies of water were observed on the premises. Medications are stored in a dining room cabinet that is secured with a master lock. Resident bedrooms had the required furniture and lighting and resident bathrooms had grab bars in the shower. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Additional food, water and incontinent supplies are stored in the garage. LPA reviewed random staff and resident files. Resident files reviewed had signed admission agreements and updated medical assessments. Staff present had a criminal record clearance and a valid first aid/CPR certification.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where this report was reviewed and provided to Administrator Otbo.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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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