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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002478
Report Date: 06/23/2022
Date Signed: 06/23/2022 12:05:40 PM


Document Has Been Signed on 06/23/2022 12:05 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 CREST GUEST HOME # 1FACILITY NUMBER:
306002478
ADMINISTRATOR:KENNETH/MARIA HUNTERFACILITY TYPE:
740
ADDRESS:8052 SAN LUCAS CIRCLETELEPHONE:
(714) 229-0662
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:4CENSUS: 1DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Kenneth HunterTIME COMPLETED:
12:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by Administrator (AD) Kenneth Hunter. AD Hunter has a current administrators certificate that expires 6/16/23.

Around 10:08 am LPA Haley and AD Hunter began a tour of the facility. A two-story structure with three rooms down stairs and three rooms upstairs. Residents reside down stairs and upstairs is off limits to residents. Currently there is one resident in the facility and he was present for todays visit. LPA observed all a screening log book for residents and visitors next to the front door. There was a temperature thermometer, hand sanitizer, and face mask near by.

LPA Haley and AD Hunter toured the kitchen around 10:12 am. The knives and sharp objects were locked in a kitchen drawer. All five burners were operational. The facility has a two day supply of perishable food items and a seven day supply of nonperishable food items. All hazardous chemicals were locked in a cabinet near the washer and dryer. LPA Haley observed a locked medication cabinet in the dining room.

Around 10:25 am LPA Haley and AD Hunter toured resident rooms and bathrooms. All resident bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. LPA Haley observed one resident in his room on his laptop computer, the other resident rooms were vacant. . Bathroom #1 the water temperature measured at 120.2 degrees Fahrenheit, and 120 degrees Fahrenheit in bathroom #2. In the hallway there was plenty of clean linen. LPA Haley took a look in the upstairs portion of the facility and observed AD Hunter's living and office space.

Around 10:32 am we toured the back yard and garage area. There was a pool surrounded by a secured fence that meets regulations. The exit gate was self closing and self latching. There was a shad area with a table and chairs. The garage remains locked and inaccessible to the resident in care.

CONTINUED ON LIC 809C DATED 06/23/2022.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUNNY CREST GUEST HOME # 1
FACILITY NUMBER: 306002478
VISIT DATE: 06/23/2022
NARRATIVE
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At 10:42 am smoke and carbon monoxide detectors were tested and operational. The fire extinguisher was observed and charged.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.


An exit interview was conducted. A copy of this report along with the appeal rights were provided to AD Hunter.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/23/2022 12:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: SUNNY CREST GUEST HOME # 1
FACILITY NUMBER: 306002478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456
(a)(8)(A)(B)(C)(D) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall conatin at least the following: Sterile first aid dressings. Bandages or roller bandages. Scissors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and statement from Administrator Hunter the facility does not have a first aid kit available. The licensee did not comply with the section cited above which poses a potential health and safety risk to residents in care.
POC Due Date: 06/30/2022
Plan of Correction
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The licensee will purchase a complete first aid kit and send LPA Haley proof of purchase.
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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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