306005153-4-3-2024-22-AS-RQUZ-D3YVPJ-20240403163650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005153
Report Date: 04/03/2024
Date Signed: 04/03/2024 04:37:21 PM

Document Has Been Signed on 04/03/2024 04:37 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:	SUNNY DAYS HOME CARE 1		FACILITY NUMBER:	306005153
ADMINISTRATOR:	HAN, CLARA JEESUK		FACILITY TYPE:	740
ADDRESS:	9448 KIWI CIRCLE		TELEPHONE:	(714) 968-4909
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	04/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Clara Han, Licensee/Administrator		TIME COMPLETED:	04:40 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

On today's date, Licensing Program Analysts (LPAs) LPA Rosie Quiroz made an unannounced visit on this day for the purpose of conducting an Annual Required-1 year inspection visit. LPA Quiroz was greeted by Caregiver (CG) 1. Licensee/Administrator (L/AD) Clara Han arrived shortly after and discussed purpose of the visit.

The facility is a one story home which consists of: 4 private resident bedrooms, 1 shared resident bedroom, 1 caregiver bedroom, 2 bathrooms for residents, 1 bathroom designated for staff and visitors, living-room, kitchen with dining area, back yard with ample shade and outdoor furniture, garage with operational washer and dryer.

The facility is licensed for age range 60 and over, 6 Non-Ambulatory residents, and has a hospice waiver for 4 residents. There is currently (1) one resident currently receiving hospice care services.

Administrator Clara Han has a current Administrator's certificate which expires on 2/10/2025.

LPA Quiroz along with CG1 toured the interior and exterior of facility. LPAs observed kitchen for proper sanitation and cleanliness. LPAs observed Sharp objects locked and secured in cabinet in kitchen area, and observed toxin substances to be locked and inaccessible to residents in care in locked and secured closet in garage area. The food was observed to meet the minimum requirement of two days perishable and seven days nonperishable food supply for residents in care.

Six of six resident bedrooms were observed to have required furnishings including but not limited to: lamp, bed, mattress, night stand and clean linen. LPA Quiroz interacted and interviewed 6 of 6 residents during facility tour. The water temperature in 3 of 3 resident bathrooms were measured to be within normal limits. The Grab bars and non-slip mats were observed in resident bathrooms. Room temperature inside the facility was recorded to be 74 degrees F.

CONTINUED NEXT LIC 809-C PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
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)

Page: 1 of 2

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: 04/03/2024

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
26
27
28
29
30
31
32

CONTINUED...The outside grounds were inspected during facility tour, and no bodies of water were observed. No pool available at this facility. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPAs observed one fire extinguishers mounted and charged in kitchen area, which was last serviced on 4/23/2023. LPAs observed and tested functional and operational carbon monoxide and smoke alarms. (AD) Clara Han reports fire drills are conducted bi-monthly with staff and residents. Last facility fire drill was conducted on October 7,2023 indicating " We will be conducting a fire drill this week." (AD) Clara Han reported offering the following indoor and outdoor activities at the facility according to weather conditions: "Ball throwing exercises, puzzles, outdoor walks in wheelchairs, board games and bike peddling exercises." LPA Quiroz reviewed whether the facility is operating within capacity limitations and reviewed repeated violations, no repeated violations assessed.

During today's visit, LPAs reviewed resident and personnel records. 6 of 6 Resident files and 4 of 4 personnel files were found to be within Title 22 California Code of Regulations. LPA Quiroz reviewed centrally stored medications during today's visit. (See LIC 9102-TV)

Based on the observations made during today’s visit; there are no deficiencies being cited per Title 22 Division 6 of the California Code of Regulations. This report was read and reviewed with (L/AD) Clara Han, and a copy of this report, LIC 858, LIC 859 and LIC 9102-TV pages were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
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

LIC809 (FAS) - (06/04)

Page: 2 of 2