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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004563
Report Date: 10/08/2021
Date Signed: 12/29/2021 06:30:04 PM

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 ASSISTED LIVING AT LA PALMAFACILITY NUMBER:
306004563
ADMINISTRATOR:MUNOZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5321 LA PALMA AVETELEPHONE:
(714) 739-8111
CITY:LA PALMASTATE: CAZIP CODE:
90623
CAPACITY:80CENSUS: 69DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Administrator Jennifer MunozTIME COMPLETED:
02:04 PM
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Licensing Program Analyst (LPA), Shobhana Frank conducted an unannounced Required 1 year inspection today. Upon arrival LPA met administrator Jennifer Munoz.
Facility is licensed for eighty (80) Non Ambulatory capacity of which nine (9) may be bedridden, approved for (20) hospice waiver.
LPA observed the screening/sanitizing station at the entrance of the facility. Visitors sign in and are screened for temperature. Facility takes residents temperatures daily and documents. Facility has COVID precaution postings as well as all required department postings. Facility has completed the Mitigation Plan and is approved. LPA was screened for COVID 19 at the screening/sanitizing station.
During today's visit LPA toured the facility with the Administrator Jennifer Munoz, all areas of the facility related to residents care were toured including activity areas. Facility fire clearance is maintained in conformity with State Fire Marshall regulations; Fire extinguishers were mounted and charged, Smoke detectors and Carbon monoxide detectors meet the regulatory requirements. All disinfectants, cleaning solutions, and poisons were inaccessible to residents. All toilets, hand washing facilities and areas are maintained in a safe, sanitary, operating condition. LPA inspected the kitchen for cleanliness; facility refrigerators and other appliances inspected to ensure that they are all in operating condition. Inspected the facility 2 days perishable, 7 days’ nonperishable food supply and the facility emergency supplies for the residents in care. The facility was noted to be clean, safe, and sanitary.
Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. Staff and
most residents are vaccinated for COVID-19. Resident files contained updated emergency information as
well as required department forms.
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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