306004819-3-5-2024-22-AS-RMAZ-D33SD6-20240305124636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004819
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:46:57 PM

Document Has Been Signed on 03/05/2024 12:46 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
ORANGE COUNTY RO, 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:	03/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Shirley Villarmo		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by Irish Pepito, Caregiver and LPA explained the nature of the visit. Shirley Villarmo, Administrator arrived shortly after and met with LPA. There are six residents at the facility and there are three residents receiving hospice services currently. LPA accompanied with caregiver began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage in freezer in garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 105.9 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in laundry unit and locked in garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. LPA observed shared bedroom to have three beds, caregiver verified there are three residents residing in shared bedroom. LPA observed there are three private bedrooms with one resident and components for one resident. Smoke detectors were tested and found to be operational. LPA toured the Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A1 RCFE - SUNNY HILLS	FACILITY NUMBER: 306004819
	VISIT DATE: 03/05/2024

NARRATIVE

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outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is a covered front patio with seating areas for residents. LPA observed there are several shaded seating areas for residents’ enjoyment in the backyard and front patio. LPA observed a fire extinguisher with service date of December 12, 2023, in dining room. LPA began review of records. LPA reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information.

Based on this inspection, one deficiency was observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies.

This report was reviewed with Administrator and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/05/2024 12:46 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
ORANGE COUNTY RO, 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(2)(D)

83707 Personal Accomodations and Services (a) living accomodations and grounds shall be related to the facilitie's function. The facility shall be large enough to provide comfortable living accomodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) residents bedrooms shall be provided which meet, at a ,inimum, the following requirements: (D) not more than two resident shall sleep in a bedroom. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as LPA upon tour of resident bedrooms observed three beds in a shared room. Administrator verified that there was three residents (R1, R2, & R3) resideing in the shared bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Administrator stated they will find a solution to either move one resident and make a private room shared or move out a resident from the facility following proper regulation requirements. Administrator to email a picture of the bedroom once resident has been moved out of the shared bedroom and/or keep LPA informed of the status. LPA to conduct an inspection visit upon POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC809 (FAS) - (06/04)

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