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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005223
Report Date: 12/22/2023
Date Signed: 12/22/2023 10:12:20 AM


Document Has Been Signed on 12/22/2023 10:12 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:SUNNYCREST SENIOR LIVINGFACILITY NUMBER:
306005223
ADMINISTRATOR:AGUIRRE, MONICAFACILITY TYPE:
740
ADDRESS:1925 SUNNY CREST DRIVETELEPHONE:
(714) 992-1999
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:210CENSUS: 91DATE:
12/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Melanie Washington- Executive DirectorTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting a Case Management visit. LPA explained the nature of the visit to Executive Director Melanie Washington.
On December 20, 2023, LPA obtained knowledge of the following during the investigation in connection to Complaint Control Number: 22-AS-20230911142552.

The facility did not submit a written report within seven days of the occurrence pertaining to the skin tear Resident #1 (R1) sustained from the fall by the rose bush on June 1, 2022. Per Progress Notes, resident had a change of condition after a fall and sustained an injury on September 23, 2023. Facility did not have an updated Physician’s Report or a doctor’s order prescribing the wheelchair.

As a result of today’s Case Management visit, Technical Violation Advisory notes will be issued.

An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report along with Technical Violation Advisory Notes form LIC9102s and the LIC811 were provided at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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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