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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004819
Report Date: 03/22/2022
Date Signed: 03/22/2022 04:56:49 PM


Document Has Been Signed on 03/22/2022 04:56 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:A1 RCFE - SUNNY HILLSFACILITY NUMBER:
306004819
ADMINISTRATOR:VILLARMO, SHIRLEYFACILITY TYPE:
740
ADDRESS:811 WILDROSE DRIVETELEPHONE:
(714) 388-8895
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 6DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Administrator, Shirley HillsTIME COMPLETED:
05:00 PM
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LPAs Jenifer Tirre and Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were greeted and granted entry by Administrator Shirley Hills, with a valid administrator certificate that expires on 02/14/2023. At entry LPAs temperatures were taken and documented. There is a designated sign in and temperature station at entry of home.

At 3:30pm PM, LPAs toured the facility with Shirley Hills,Administrator. Facility has 6 residents present during today's visit. LPAs observed clients relaxing in the facility. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Facility uses a handwritten sign in/ questionnaire. Facility takes residents and staff temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. The facility mitigation plan has been completed and approved. LPAs observed adequate emergency food and water. LPAs observed locked medication cabinet. Fire extinguishers are mounted and charged. LPAs toured the outside grounds and observed multiple outside shaded visitation areas. Exit gates are unlocked and self latching. LPAs observed activity of exercising. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. LPAs observed an ample supply of PPE. All staff and residents are vaccinated for Covid-19. LPAs reviewed all resident files and all contained required documentation including updated emergency information and current physician report.

This report was discussed with the administrator and a copy was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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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