306004049-8-19-2024-22-AS-BALN-D8AU9M-20240819152323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004049
Report Date: 08/19/2024
Date Signed: 08/19/2024 03:23:27 PM

Document Has Been Signed on 08/19/2024 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ROSSMOOR SUNSHINE VILLA-WEMBLEY		FACILITY NUMBER:	306004049
ADMINISTRATOR:	ROBERT DALE KALAGAYAN		FACILITY TYPE:	740
ADDRESS:	11322 WEMBLEY ROAD		TELEPHONE:	(562) 493-3987
CITY:	LOS ALAMITOS	STATE: CA	ZIP CODE:	90720
CAPACITY:	6	CENSUS: 5	DATE:	08/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Maria Tavarez support staff		TIME COMPLETED:	03:35 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 Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Maria Tavarez support staff who granted entry into the facility.

LPA observed 3 staff and 5 residents during the inspection.The facility is licensed for 6 non-ambulatory,of which 1 may be bedridden. Hospice waiver for 4.The facility is operating in the capacity and conditions approved by CCL.

Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected clients bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

The hot water temperature tested within regulation at 104 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked in a cabinet over the kitchen sink. There was a designated place for client/staff files locked in closet, Overall, the facility appeared to be clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: ROSSMOOR SUNSHINE VILLA-WEMBLEY	FACILITY NUMBER: 306004049
	VISIT DATE: 08/19/2024

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
26
27
28
29
30
31
32

Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians.

LPA also reviewed two (2) staff files for First Aid/CPR certification, training's, and health screenings and appeared to be current.

Based on the observations made during today’s visit, no deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Maria Tavarez support staff at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2