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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002568
Report Date: 09/29/2021
Date Signed: 10/22/2021 11:58:55 AM

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:SUNRISE AT YORBA LINDAFACILITY NUMBER:
306002568
ADMINISTRATOR:MARIA DOMINGOFACILITY TYPE:
740
ADDRESS:4792 LAKEVIEW AVETELEPHONE:
(714) 693-5368
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:93CENSUS: 75DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maria Domingo, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Kathrina Chin conducted an unannounced required annual inspection in this facility. LPA met with Maria Domingo, Executive Director and stated the purpose of this visit.

LPA Chin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. Facility has 75 residents in care and fifteen staff members on the floor. LPA toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 114.9 F degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair, and grounds were free of tripping hazards. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies.

LPA Chin reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Chin conducted an exit interview with Maria Domingo, Executive Director and copy of this report was left in the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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