306005479-3-4-2025-22-AS-EKIM-DEG2LP-20250304162954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005479
Report Date: 03/04/2025
Date Signed: 03/04/2025 04:30:03 PM

Document Has Been Signed on 03/04/2025 04:30 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:	ROSSMOOR SUNSHINE VILLA-OAK WAY		FACILITY NUMBER:	306005479
ADMINISTRATOR/ DIRECTOR:	JULIO NAVALLO		FACILITY TYPE:	740
ADDRESS:	12772 OAK WAY DRIVE		TELEPHONE:	(562) 572-9931
CITY:	ROSSMOOR	STATE: CA	ZIP CODE:	90720
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Assistant Administrator- Maria Tavarez		TIME VISIT/ INSPECTION COMPLETED:	04:35 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 March 4, 2025, at 1:30 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Eloisa Reyes. Assistant Administrator (AA) Maria Tavarez arrived at the facility around 1:40 PM and LPA explained the purpose of the visit. The facility is licensed to operate for six (6) nonambulatory residents, of which two (2) may be bedridden, and has a hospice waiver for five (5) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, seven (7) bathrooms, living area, dining area, kitchen, an outdoor patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with AA Tavarez. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5, and Resident Room 6. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 111.5 degrees F to 113.5 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility. LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly. Evaluation Report Continues on LIC 809-C

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 03/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSSMOOR SUNSHINE VILLA-OAK WAY	FACILITY NUMBER: 306005479
	VISIT DATE: 03/04/2025

NARRATIVE

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A working telephone (562-357-4717) remains available. Last emergency drill was conducted on February 19, 2025. Two fire extinguishers are charged and mounted in the kitchen and in the entrance hallway. Emergency food, emergency water, and emergency supplies are stored in the garage. Facility has evidence of liability of insurance effective June 22, 2024, and expires June 22, 2025. LPA Kim conducted an audit of medication and medication administration record that was in order and complete.

Due to time constraints a continuation inspection will be on a later date. LPA Kim will conduct an audit review of staff records, resident records, staff/resident interviews, an audit of first aid kit, and make sure the smoke detectors and carbon monoxide detectors are operational.

A deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). Prior to construction or alterations, facility built an enclosed storage room in the garage with an additional two built walls.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Assistant Administrator Maria Tavarez.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/04/2025 04:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSSMOOR SUNSHINE VILLA-OAK WAY	FACILITY NUMBER: 306005479
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed that there is an enclosed storage room in the garage with an additional two built walls that is not shown on the facility sketch. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/18/2025
	Plan of Correction
1 2 3 4	Licensee states they will go and obtain building permit, or approval, from the city of Rossmoor, or the Orange County, Building Department of the enclosed room with an additional two built walls. They will send proof to CCLD via email to Edward.Kim@dss.ca.gov by POC due date March 18, 2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 03/04/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

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