306002918-10-21-2022-22-AS-JCHO-CKEU8N-20221021152149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002918
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:22:51 PM

Document Has Been Signed on 10/21/2022 03:22 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:	SUNNY HILLS HOMES		FACILITY NUMBER:	306002918
ADMINISTRATOR:	MARIA/NESTOR MOYA		FACILITY TYPE:	740
ADDRESS:	25402 COSTEAU DRIVE		TELEPHONE:	(949) 370-6639
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	5	CENSUS: 4	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:52 PM
MET WITH:	Maria & Nestor Moya		TIME COMPLETED:	03:40 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	On 10/21/2022 at 12:52pm, Licensing Program Analyst (LPA) Jessica Cho arrived at Sunny Hills Homes to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year with an emphasis on Infection Control. At 12:56pm, LPA Cho was greeted and granted entry by Licensee/Administrator (Admin) Maria Moya. LPA completed the Coronavirus 2019 (COVID-19) screening procedure and also met with Licensee/Co-Administrator (Admin) Nestor Moya. There are no active COVID-19 cases as of today. Facility does not document daily temperatures of visitors on a sign in sheet. COVID-19 symptom checks are conducted and documented daily for residents and staff. LPA observed the required COVID-19 precautionary signs posted on the front entrance and in the entryway. The Complaint Poster (PUB475) did not meet the size requirement. The facility is licensed for five non-ambulatory residents and has a hospice waiver for four. There are currently four residents living in the facility of which none are receiving hospice care. At 10:19am, LPA Cho conducted a tour of the physical plant with Licensee/Administrator Maria Moya. The two-story home consists of three resident bedrooms and two resident bathrooms. The Licensees/Administrators live on the second floor of the facility and occupy three bedrooms. The facility also has a living room, kitchen, and garage with laundry. LPA inspected the resident bedrooms. The resident bedrooms had the required furnishings. LPA observed Ring motion-detector cameras in each of the three resident bedrooms. Per Admin, the cameras were not connected but is only utilized in the evenings. LPA verified that the cameras were not in use at initial inspection. Admin indicated that audio is present and has microphone capabilities to communicate with residents. After an extensive consultation, Licensees/Administrators expressed of wanting to continue using the cameras in the resident bedrooms in the evenings and has agreed to submit a waiver to the Department. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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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Document Has Been Signed on 10/21/2022 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY HILLS HOMES	FACILITY NUMBER: 306002918
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.2(a)(1)

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.2, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews of licensees, the facility utilizes a camera in three of three resident bedrooms and is not providing all four residents a reasonable level of personal privacy which poses a potential Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 10/31/2022
	Plan of Correction
1 2 3 4	Licensees agree to submit a camera waiver to LPAs Ruth Martinez and Jessica Cho by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY HILLS HOMES	FACILITY NUMBER: 306002918
	VISIT DATE: 10/21/2022

NARRATIVE

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LPA observed hand washing signs in the bathrooms. LPA Cho tested the hot water temperatures and the water temperatures measured at 118.7 degree Fahrenheit in Bathroom #1 and 118.2 degree Fahrenheit in Bathroom #2. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were mounted, fully charged, and serviced on 10/21/2022. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit gate was self-closing and self-latching. LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Administrator Maria Moya, and a copy of this report (along with LIC809, LIC809C, LIC809D, LIC811 and the appeal rights) were provided to Administrator Maria Nestor via email due to insufficient toner.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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