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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 05:27:35 PM
Document Has Been Signed on
03/22/2022 05:27 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 HILLS
FACILITY NUMBER:
306004819
ADMINISTRATOR:
VILLARMO, SHIRLEY
FACILITY TYPE:
740
ADDRESS:
811 WILDROSE DRIVE
TELEPHONE:
(714) 388-8895
CITY:
BREA
STATE:
CA
ZIP CODE:
92821
CAPACITY:
6
CENSUS:
6
DATE:
03/22/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
05:00 PM
MET WITH:
Administrator, Shirley Hills
TIME COMPLETED:
05:30 PM
NARRATIVE
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On this day Licensing Program Analysts (LPA) Jenifer Tirre and Andrea Mendivil made an unannounced visit to conduct an annual inspection visit. During the walk through visit LPA's observed Medication that was left out and not in a secured location. Facility has dementia residents in care. Administrator quickly stored medication in locked medication cabinet at LPA's request.
LPA's discussed violation of Title 22 regulations and a copy of report was left at facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Jenifer Tirre
TELEPHONE:
(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)
Page:
1
of
2
Document Has Been Signed on
03/22/2022 05:27 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
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 HILLS
FACILITY NUMBER:
306004819
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited
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87465(h)(2) incidental medical and dental care (h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Jenifer Tirre
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/22/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/22/2022
LIC809
(FAS) - (06/04)
Page:
2
of
2