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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004819
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:23:32 PM


Document Has Been Signed on 04/03/2024 12:23 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 HILLSFACILITY NUMBER:
306004819
ADMINISTRATOR:VILLARMO, SHIRLEYFACILITY TYPE:
740
ADDRESS:811 WILDROSE DRIVETELEPHONE:
(714) 388-8895
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 5DATE:
04/03/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Irish PepitoTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of conducting a POC inspection to verify correction of citation issued during the annual visit conducted on March 05, 2024. LPA arrived at the facility and was greeted and granted entry to the facility by staff. LPA met with Irish Pepito, care staff and explained the nature of the visit.

Upon entry LPA observed that residents were getting ready for lunch and were sitting in the dining room. There were five residents in care present at the facility and two staff at the time of visit. LPA toured the physical plant of the facility and inspected the resident bedrooms. LPA observed that resident bedrooms are two shared and two private. It was observed that bedrooms one and five are now shared bedrooms with two resident per. Bedrooms two and three are private with one resident per.

Based upon this inspection, LPA observed the following:

*Deficiency cited under Title 22 Regulation 87307(a)(2)(D) has been cleared. The licensee complied with the terms of the citation by POC due date.



LPA at the time of visit cleared the POC, generated a letter of deficiency citations cleared, and left a copy of the letter at the facility for their records.

Exit interview was conducted with facility representative and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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