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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005223
Report Date: 04/25/2022
Date Signed: 04/25/2022 04:55:39 PM


Document Has Been Signed on 04/25/2022 04:55 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:SUNNYCREST SENIOR LIVINGFACILITY NUMBER:
306005223
ADMINISTRATOR:SARAH CLEESENFACILITY TYPE:
740
ADDRESS:1925 SUNNY CREST DRIVETELEPHONE:
(714) 992-1999
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:210CENSUS: 85DATE:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Sarah Cleesen, Executive DirectorTIME COMPLETED:
05:00 PM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA), Kathrina Chin. LPA met with Sarah Cleesen, Executive Director and explained the purpose of the visit. This is a follow up to an incident report which occurred on 12/5/2021. The facility caregiver discovered a resident was deceased at 8:25 am on 12/5/ 2021 in his apartment unit. The medication technician called 911 emergency personnel and was advised to do chest compression until paramedics arrived. The paramedics and the police arrived at the community and the body was released to the Mortuary.

LPA requested a copy of the resident 1's physician's report, Needs and Services plan and pre-admission appraisal. Sarah Cleesen, ED stated that she will be looking for the file for the resident tomorrow with her Regional Director.


At this time, based on the information available, there are no deficiencies being cited per Title 22 of the California Code of Regulations.

An exit interview interview was conducted and a copy of this report provided to the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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