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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002644
Report Date: 04/04/2022
Date Signed: 04/04/2022 02:17:17 PM


Document Has Been Signed on 04/04/2022 02:17 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:SUNRISE OF MISSION VIEJOFACILITY NUMBER:
306002644
ADMINISTRATOR:PSENECNIK, ROXANNEFACILITY TYPE:
740
ADDRESS:26151 COUNTY CLUB DRTELEPHONE:
(949) 582-2010
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:110CENSUS: 87DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Roxanne Psebecnik, Roanna CruzTIME COMPLETED:
02:26 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA met with Resident Care Director (RCD) Roanna Cruz and Executive Director (ED) Roxanne Psenecnik . LPA explained the reason for the visit. LPA and the Executive Director toured the facility. Facility is one building with 3 levels. The bottom floor is the memory care unit. LPA tested the delayed egress exit door in the memory care patio. The delayed egress exit door functions properly, the alarm was triggered/sounded and the door opened after 15 seconds .LPA observed a small fountain in the patio. The fountain is surrounded by a small hedge and the fountain water level is under 2 inches deep. No obstacles or hazards observed in the patio. LPA observed the resident rooms in memory care had the required furnishings. The first and second levels are for assisted living. LPA observed the medication carts are kept locked so residents do not have access to the medication cart. LPA observed the kitchen had a 2 day perishable and 7 day non-perishable food supply on hand. The kitchen was clean and organized. LPA observed the emergency water and food supply is kept secured in a storage room. LPA observed the resident rooms on the first and second level (memory care unit is below the first level) had the required the furnishings. LPA observed an evacuation chair in the Southwest stairwell. LPA observed all fire extinguishers are fully charged. The last fire drill was conducted on 3/28/2022. The automatic fire sprinkler system was tested on 2/21/2022 with no deficiencies. No obstacles or hazards observed inside of the facility. Facility has submitted a mitigation plan that is pending approval. LPA consulted with the Executive Director concerning continued mitigation requirements and reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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