306002644-4-19-2024-22-AS-JCHO-D4H35Q-20240419175708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002644
Report Date: 04/19/2024
Date Signed: 04/19/2024 05:57:17 PM

Document Has Been Signed on 04/19/2024 05:57 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:	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: 91	DATE:	04/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Tisset Domingo- Executive Director		TIME COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Jessica Cho, Edward Kim, Faith La, and Licensing Program Manager (LPM) Lourdes Montoya arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPAs and LPM explained the purpose of the visit to Executive Director (ED) Tisset Domingo. The facility is licensed for 110 and maintains a hospice waiver of 17. As of today, the resident census is 91 of which 8 are receiving hospice care. At or approximately 9:34am, LPAs and LPM conducted a tour of the physical plant accompanied by the ED, and the following were observed: This is a three-story facility comprised of an Assisted Living (AL) on the 1st and 2nd floors, and Memory Care on the Terrace Level. LPAs inspected all common areas which includes but is not limited to: the public bathrooms, shared/private dining areas, storage/supply rooms, living room, Activity Rooms, Beauty Salon, laundry rooms, Housekeeping closet, Wellness Room, and Staff Break/Training Room. LPAs inspected ten resident bedrooms which had all the required elements with ample lighting. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the non-skid mats were in place. The hot water temperature measured within the required range of 105-120 degrees Fahrenheit. LPAs inspected the kitchen and the dining area. Facility maintains ample supply of two-day perishables and seven-day non-perishables. LPA observed the emergency food and water in the storage room in the Terrace Level. The fire extinguishers were mounted, fully charged, and serviced on October 2, 2023 and October 26, 2023. The smoke detectors were last tested on April 26, 2023 by Johnson Controls and verified on the inspection report. LPAs toured the outside grounds. There were sufficient seating and shading for the residents, and the walkways were clear of hazards. All exit gates were self-closing and self-latching.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNRISE OF MISSION VIEJO	FACILITY NUMBER: 306002644
	VISIT DATE: 04/19/2024

NARRATIVE

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LPAs reviewed ten residents’ files. No discrepancies noted. LPAs reviewed 10 staff files. No discrepancies noted. Interviews were conducted with ten residents and staff. The medications and the Medication Administration Records (MARs) were reviewed for five residents. No discrepancies noted.

The following postings were reviewed and observed: Complaint Poster (PUB475) in the size of 8.5"X11", food menu, activities, client’s rights, and the Emergency Disaster Plan (LIC610D). In addition, facility maintains sufficient PPEs and first aid supplies.

The following were advised: to maintain the PUB475 in the size of 20"X26" in the main entryway and to complete include identification of an assembly point(s) on the facility sketch in reference to the LIC610D.

Based on the observations, no deficiency is being cited as per the Title 22, Division 6, Chapter 6 of the California Code of Regulations. Two Technical Violations (TVs) were issued.

An exit interview was conducted with Executive Director Tisset Domingo, and a copy of this report including the LIC9099C and TVs were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

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