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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005153
Report Date: 12/16/2022
Date Signed: 12/16/2022 11:38:58 AM

Document Has Been Signed on 12/16/2022 11:38 AM - 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:SUNNY DAYS HOME CARE 1FACILITY NUMBER:
306005153
ADMINISTRATOR:HAN, CLARA JEESUKFACILITY TYPE:
740
ADDRESS:9448 KIWI CIRCLETELEPHONE:
(714) 968-4909
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
12/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Clara Han, Licensee/AdministratorTIME COMPLETED:
11:40 AM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced case management visit to follow up on an Incident report dated 12/11/2022 received in the Orange County Regional Office on 12/12/2022. LPA met with Licensee/Administrator (L/AD) Clara Han and explained the reason for the visit.

Incident report dated 12/11/2022 indicated that on 12/10/22 on or about 8:41pm Resident 1 pressed facility call button with no response then called local fire department. Fountain Valley Fire Department (FVFD) arrived to the facility on or about 8:46pm with no staff present at the facility and six residents inside the facility. FVFD called Licensee/Administrator Clara Han on or about 8:46pm to discuss incident. Staff 1 (S1) and Staff 2 (S2) arrived to the facility between 8:50pm-8:55pm.
During today's visit, LPA Quiroz along with (L/AD) Clara Han conducted tour of interior and exterior of facility premises. During today's visit, LPA Quiroz conducted interviews with Resident 3, Resident 4, Resident 5, Resident 6, Staff 1, Staff 2 and Licensee/Administrator Clara Han and reviewed documents for six of six residents but not limited to: Physician report, identification form and needs and services plan. Based on documentation review, four of six residents residing at the facility have a Dementia diagnose identified on their LIC 602 (Physician Report).

LPA Quiroz provided consultation to Licensee/Administrator Clara Han and Facility staff regarding California Code of Regulation (CCR) Care of Persons with Dementia: 87705.

Based on today's observations and documentation review, facility is being cited per Title 22,(CCR) Care of Persons with Dementia: 87705(c)(4).(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4)There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.

CONTINUED ON NEXT PAGE...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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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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: SUNNY DAYS HOME CARE 1
FACILITY NUMBER: 306005153
VISIT DATE: 12/16/2022
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This report was reviewed with L/AD Clara Han, and a copy of this report, Appeal Rights, LIC 809-D, LIC 811-Confidential Names and copy of CCR Care of Persons with Dementia-87705 were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2022 11:38 AM - It Cannot Be Edited


Created By: Rosie Quiroz On 12/16/2022 at 11:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY DAYS HOME CARE 1
FACILITY NUMBER: 306005153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2022
Section Cited

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Care of Persons with Dementia: 87705(c)(4).(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4)There is an adequate number of direct care staff to support each resident’s physical, social, CONTINUED BELOW.
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CONT...emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: On 12/10/22 on or about 8:41pm, FVFD arrived to the facility... there were no staff present at the facility and 6 residents inside the facility. This was verified with L/AD Han
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POC will be provided to CCLD by POC due date of 12/19/2022.


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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
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022


LIC809 (FAS) - (06/04)
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