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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005547
Report Date: 05/31/2023
Date Signed: 05/31/2023 04:13:49 PM

Document Has Been Signed on 05/31/2023 04:13 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:SUNNYWOOD HOUSEFACILITY NUMBER:
306005547
ADMINISTRATOR:HILLMAN, HELENFACILITY TYPE:
734
ADDRESS:2913 SUNNYWOOD DRTELEPHONE:
(657) 378-9137
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 5CENSUS: 4DATE:
05/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Desiree LascanoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Lydia Martinez conducted an unannounced Required - 1 Year inspection. LPA Martinez was granted entry into the facility by Staff and reason for the visit was explained. Facility operates an Adult Residential Facility for Persons with Special Health Needs (ARFPSHN). Staff stated Administrator Helen Hillman is on a leave and Desiree Lascano is Acting Administrator (AD). AD Lascano arrived shortly after.

The facility is a one story home with (5) bedrooms and (2.5) bathrooms with an attached 2 car garage used for storage. No pools or bodies of water were observed. No firearms are being kept at the facility. The clients served are adults between the ages of 18 to 66 with special health care needs. LPA along with Nurse Bauzon conducted a tour of the interior and exterior of the facility, reviewed facility documents and conducted staff and attempted client interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had Infection Control Training.



Physical Plant: LPA observed client bedrooms. facility floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature is within regulation. Video cameras are installed outside the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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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: SUNNYWOOD HOUSE
FACILITY NUMBER: 306005547
VISIT DATE: 05/31/2023
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Food Service: LPA observed facility kitchen to be clean and equipment was in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. The facility currently has (2) clients that eat pureed foods and the other 2 clients utilize a G-tube.

Care & Supervision/Administration: Adequate staff for the number of client's in care were present during today's visit. LPA inquired about activities that are being provided to the clients; per Staff they go for walks, shopping, have sensory items, coloring, paint, outings, and they love to listen to music. LPA observed C2 was watching a movie in the living room area during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility.

Record Review and Resident/Staff Files: LPA reviewed (4) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Four (4) client files were reviewed, and possessed all required paperwork. LPA noted Administrator Helen Hillman's Certificate expired on 12/10/2022. Acting Administrator Desiree Lascano's Administrator Certificate expires on 02/23/2025.

Health Related Services/Incidental Medical Services: All client medication was locked in Medication cabinet. LPA reviewed client medications and found all medication listed on MARS and all required labeling was found to be in place. LPAs also observed Hoyer lifts and medical supplies such as feeding tube supplies and sanitizing supplies.

Disaster preparedness: LPA reviewed the facility's Emergency Disaster Plan. Fire drills are conducted once a month and LPA verified last Fire Drill was conducted on 05/10/2023. Fire Extinguishers were observed mounted and last charged on 03/21/2023. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and First Aid Kit with all required items. There is an Electric Generator and Back up Propane Gas available.

Based on today's inspection, no deficiencies were observed at this time in the areas evaluated. An exit interview was conducted with Staff Candice Ayala and the following reports: LIC809, LIC 809C, LIC9102, LIC811 and copy of Regulation 85608 will be sent to the email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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