<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005701
Report Date: 03/08/2023
Date Signed: 03/08/2023 04:01:23 PM

Document Has Been Signed on 03/08/2023 04:01 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:SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTERFACILITY NUMBER:
306005701
ADMINISTRATOR:MICHAEL VILLARREALFACILITY TYPE:
772
ADDRESS:25481 GLORIOSA DRIVETELEPHONE:
(949) 533-3046
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Raze Cameraj, Usha Villarreal, Michael VillarrealTIME COMPLETED:
04:15 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
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff #1 (S1) Raze Cameraj and discussed the purpose of the inspection. Chief Executive Officer (CEO) Usha Villarreal arrived at about 10:10AM. Administrator (AD) Michael Villarreal arrived around 11:30AM. LPA toured the facility with S1 and AD.

At about 10:00AM, LPA reviewed Infection Control requirements. At about 10:30AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure. This is a two-story home. Facility is a 3-bedroom, 3-bathroom, two-story house with no staff rooms and an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed there were 3 staff and 4 clients present. Client Bedrooms. The 3 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedrooms. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114.8 and 114.9 F degrees. LPA inspected all rooms in the facility. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the medication cabinet. Toxins: observed locked in the garage. Medication cabinet is locked. First-Aid Kit, Activity Supplies, and Activity Calendar: observed and available. Facility’s licensing fees are fully paid. LPA left the facility at 12:00PM and returned at 12:30PM. At about 1:15PM, LPA reviewed 4 client files and 3 staff files. At about 2:30PM, LPA interviewed 4 clients and 3 staff. At about 3:15PM, LPA inspected the medications for 4 clients. Facility does not handle client money. LPA reviewed property logs for the clients present.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 03/08/2023 04:01 PM - It Cannot Be Edited


Created By: Sean Haddad On 03/08/2023 at 03:36 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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER
FACILITY NUMBER: 306005701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(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
1
2
3
4
Based on observation, the licensee did not ensure the faucet in 1 client bathroom did not exceed 120 degrees F, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/09/2023
Plan of Correction
1
2
3
4
During the inspection, licensee adjusted the water temperature so that all faucets tested between 105 and 120 degrees F.

POC CLEARED.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/08/2023 04:01 PM - It Cannot Be Edited


Created By: Sean Haddad On 03/08/2023 at 03:36 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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER
FACILITY NUMBER: 306005701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not ensure the facility had an evacuation chair at the top of the stairwell, which poses a potential health and safety risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
1
2
3
4
Licensee stated they will obtain and install an evacuation chair and submit proof to LPA by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER
FACILITY NUMBER: 306005701
VISIT DATE: 03/08/2023
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
26
27
28
29
30
31
32
During the inspection, LPA observed that 1 client faucet tested at 131.5 F degrees; LPA observed there was no evacuation chair at the top of the stairwell. During the inspection, facility staff adjusted the water temperature to within the proper ranges and LPA confirmed. POC CLEARED.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4