306005628-10-28-2022-22-AS-ETAA-CKMRUG-20221028131957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005628
Report Date: 10/28/2022
Date Signed: 10/28/2022 01:20:15 PM

Document Has Been Signed on 10/28/2022 01:20 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:	SUNNY CARE		FACILITY NUMBER:	306005628
ADMINISTRATOR:	PAO, WESLEY		FACILITY TYPE:	740
ADDRESS:	4662 SCHOOL ST		TELEPHONE:	(657) 363-8436
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 6	DATE:	10/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:41 AM
MET WITH:	Adriel Pao		TIME COMPLETED:	01:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff and stated the purpose of this visit. Licensee Adriel Pao arrived after the inspection.

The facility is a single level structure and licensed for six non-ambulatory of which six with a hospice waiver for four. One may be bedridden. This facility is a Residential Care Facility for the Elderly.

At about 11:41 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 5 resident rooms 1 of which is a shared room. The facility also had 2 staff rooms where inaccessible to residents. LPA noticed no lock for one of the staff rooms. Licensee was made aware of this and will purchase a lock. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPA noticed medications in one room. LPA checked the resident’s physician report and they are not able to self-administer medications. Licensee was made aware of citation and removed medications from resident’s room. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured from 111.2. degrees Fahrenheit. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. Facility offers a 2-car garage which is used for storage with a refrigerator, freezer and a recreational section for staff. Kitchen was kept clean and in good repair with sharps kept locked. LPA noticed stove top was not able to turn on without an ignitor. Licensee was made aware of this and will purchase a new stove/repair stove. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

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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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: SUNNY CARE	FACILITY NUMBER: 306005628
	VISIT DATE: 10/28/2022

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For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA noticed disinfectants and cleaning supplies unlocked in the side of the home. Licensee was made aware of this and locked up disinfectants and cleaning supplies.

LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, one deficiency was noted in areas observed. Two advisories were issued today.

LPA Tapia conducted an exit interview with Licensee Adriel Pao and copy of this report along with appeal rights was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/28/2022 01:20 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUNNY CARE	FACILITY NUMBER: 306005628
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

This requirement is not met as evidenced by: The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in one out of one medication was found in resident's room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2022
	Plan of Correction
1 2 3 4	Licensee removed medication from resident's room.

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.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC809 (FAS) - (06/04)

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