306002644-5-9-2025-22-AS-HGOH-DGHTJG-20250509144618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002644
Report Date: 05/09/2025
Date Signed: 05/09/2025 02:46:22 PM

Document Has Been Signed on 05/09/2025 02:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SUNRISE OF MISSION VIEJO		FACILITY NUMBER:	306002644
ADMINISTRATOR/ DIRECTOR:	MARIA T. DOMINGO		FACILITY TYPE:	740
ADDRESS:	26151 COUNTRY CLUB DRIVE		TELEPHONE:	(949) 582-2010
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 110		CENSUS: 83	DATE:	05/09/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	Maria Domingo		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Hanna Gough conducted an unannounced case management incident inspection for the purpose of following up on an incident report submitted to the Orange County Regional Office. LPA was greeted and granted entry by staff and met with Executive Director (ED) Maria Domingo.

The incident report was submitted to the regional office on May 1, 2025 stating that Resident #1s (R1) responsible party contacted the facility informing them that the resident stated that someone had “Dragged them to the bathroom”. Per the incident report a body check on R1 was made and no injuries were noted. R1 then stated to facility staff “They were being pushed in their wheelchair too fast so it felt like they were getting dragged”.

LPA reviewed documents and interviews were conducted at the time of the inspection. LPA reviewed R1s physicians report which states that R1 has a diagnosis of dementia. During interviews with Staff #1(S1) and Staff #2(S2) it was revealed that R1 was unable to recall who the caregiver was that was pushing the wheelchair and when staff asked to elaborate on being dragged R1 stated they were “Being pushed in their wheelchair and it felt like they were being dragged”. S1 and S2 both informed LPA that they have noticed a pattern of sundowning behaviors with R1 and have informed the responsible party and physician of the change in behavior. S1 has set up a meeting with R1s responsible party to go over their plan of care due to R1s change in behavior along with aggressive behaviors that have been noted towards staff. S1 informed LPA that they had a voicemail of R1s responsible party stating that they, “May have used strong wording and that R1s state of mind may not have been at 100%,” when informing the facility of the incident. R1 is currently in the hospital due to swelling in both legs and confusion.

Based on interviews and observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director Maria Domingo and a copy of this report was given at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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