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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004790
Report Date: 07/11/2022
Date Signed: 07/11/2022 05:04:00 PM


Document Has Been Signed on 07/11/2022 05:04 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:ROSSMOOR SUNSHINE VILLA-KENSINGTONFACILITY NUMBER:
306004790
ADMINISTRATOR:RICARDO BANOSFACILITY TYPE:
740
ADDRESS:11802 KENSINGTON RD.TELEPHONE:
(562) 794-9047
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 6DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee Flormine ResurreccionTIME COMPLETED:
04:37 PM
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to the facility today to conduct required 1 year inspection. During today’s visit, LPA met with Licensee Flormine Resurreccion and explain the purpose of today's visit. LPA Frank toured the facility, inspected resident rooms and bathrooms. There are 6 residents residing in the facility and no active COVID-19 cases. LPA observed 6 of 6 residents on site appeared clean and well taken care of. LPA Frank reviewed centrally stored medications and records, reviewed food services, and inspected the kitchen.
In addition, LPA Frank tested the hot water temperature, which measured 107.8 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The facility also has fire extinguisher that was mounted and charged. LPA Frank confirmed food supply 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet.
LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log, COVID posters throughout the facility. LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational Requirements.
LPA Frank reviewed : 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610E); 4.) LIC 9020A Client Roster; LIC 808) Mitigation Plan; Current Liability Insurance, Infection Control Plan.

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: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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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