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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004563
Report Date:
10/10/2022
Date Signed:
10/10/2022 01:21:10 PM
Document Has Been Signed on
10/10/2022 01:21 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:
SUNRISE ASSISTED LIVING AT LA PALMA
FACILITY NUMBER:
306004563
ADMINISTRATOR:
MUNOZ, JENNIFER
FACILITY TYPE:
740
ADDRESS:
5321 LA PALMA AVE
TELEPHONE:
(714) 739-8111
CITY:
LA PALMA
STATE:
CA
ZIP CODE:
90623
CAPACITY:
80
CENSUS:
68
DATE:
10/10/2022
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME BEGAN:
12:45 PM
MET WITH:
Jennifer Munoz- Executive Director
TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Executive Director Jennifer Munoz.
Per review annual was conducted on 09/29/2022.
No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
10/10/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/10/2022
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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