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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005547
Report Date: 07/30/2024
Date Signed: 07/30/2024 05:31:28 PM

Document Has Been Signed on 07/30/2024 05:31 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:SUNNYWOOD HOUSEFACILITY NUMBER:
306005547
ADMINISTRATOR/
DIRECTOR:		HILLMAN, HELENFACILITY TYPE:
734
ADDRESS:2913 SUNNYWOOD DRTELEPHONE:
(657) 378-9137
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 5CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Helen HillmanTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On July 30, 2024 at 1:30pm, 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 met with Administrator (AD) Helen Hillman and explained the purpose of the visit.

The facility is licensed to operate for five (5) non-ambulatory, of which five (5) can be bedridden. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) bedrooms, three (3) bathrooms, attached 2 car garage, attached 1 car garage which is an office, laundry area, living room, dining room, kitchen, and three outside covered patio area.

LPA Kim toured inside and outside of the physical plant. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Client Room 1, Client Room 2, Client Room 3, Client Room 4, and Client Room 5. Bathrooms were found to be clean and operational. The water temperature measured at 86.0 degrees F at both client bathrooms. A comfortable temperature of degrees 72 F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency Food, Emergency Water, and Emergency supply for the clients are stored in the each of the client's room. Staff have their emergency supplies stored in the laundry area. The facility has smoke detectors and carbon monoxide detectors that were operable. The facility conducted a Fire/Safety Drill on May 14, 2024 and conducts drills monthly. A working telephone (657-378-9137) remains available. First Aid Kit contained all the necessary elements.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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: SUNNYWOOD HOUSE
FACILITY NUMBER: 306005547
VISIT DATE: 07/30/2024
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During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA Kim conducted an audit of four (4) clients= (C1-C4) files, and five (5) staff #1-#5 personnel files, and medication and medication administration record that were all in order and complete. LPA conducted two (2) staff interviews.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1) a deficiency has been observed and citation issued.

An exit interview was conducted, and a copy of this report and appeal rights LIC 9058 was provided to Administrator Helen Hillman.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2024 05:31 PM - It Cannot Be Edited


Created By: Edward Kim On 07/30/2024 at 05:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNYWOOD HOUSE
FACILITY NUMBER: 306005547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with section cited above. LPA observed both resident bathrooms water temperatures measured at 86.0 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee states they will keep a water log of the two resident bathrooms every two hours for 24 hours starting at 7:00pm. Licensee will send a copy of the water log for the next 24 hours measuring every 2 hours with a photo of the water gauge temperature for every water temperature logged to CCLD via email to edward.kim@dss.ca.gov by the POC due date 7/31/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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