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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002644
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:23:48 PM


Document Has Been Signed on 12/08/2022 03:23 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: 89DATE:
12/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Tisset Domingo, Executive DirectorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to conduct a case management for three incident reports received on 09/19/2022, 11/16/2022, and 12/03/2022. LPA met with Receptionist Christina Barton followed by Assisted Living Coordinator (ALC) Michelle Pineda who then notified Executive Director (ED) Tisset Domingo of LPA's arrival. Approximately 12:00pm, LPA met ED Domingo and stated the purpose of this visit.

On today's visit, LPA conducted interviews with Resident 1(R1)- Resident 3 (R3) and staff. LPA obtained pertinent records for R1-R3. There were no immediate health and safety concerns.

There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Executive Director Tisset Domingo, and a copy of this report along with the LIC 811 were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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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