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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004563
Report Date: 04/29/2022
Date Signed: 05/05/2022 11:23:38 AM


Document Has Been Signed on 05/05/2022 11:23 AM - 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: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: 63DATE:
04/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Administarator Jennifer MunozTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for SIR follow up regarding R 1. Administrator Jennifer Munoz confirmed currently there are no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility. Facility is taking residents temperatures and documenting results.
LPA spoke with administrator Jennifer Munoz who reported that R 1 resides at the facility as of 2/17/22. On 4/19/22 R 1's daughter took R 1 to the hospital and R 1 never came back to the facility. On 4/23/22 R1’s daughter came at the facility and pick up all the belongings. Administrator reported that she had contacted the daughter to gather information regarding R 1's returning to the facility. Daughter never disclosed any information to administrator.LPA Frank obtained document related to the resident.


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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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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