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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005701
Report Date: 03/20/2024
Date Signed: 03/20/2024 07:10:41 PM

Document Has Been Signed on 03/20/2024 07:10 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: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: 5DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Andrew Crawford- Program DirectorTIME COMPLETED:
07:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit unannounced after a conducting the 10-day complaint investigation in connection to Complaint Control Number: 22-AS-20240314164054. The purpose of this visit was to conduct the required annual inspection. LPA was assisted by Program Director Andrew Crawford and explained the reason for the visit.

This facility is a two-story residential home comprised of three client bedrooms, two client bathrooms, one staff bathroom, formal living/family room, dining area, kitchen, laundry room, medication office, a therapy shed in the backyard, and a two-car garage. LPA observed clutter of items that was blocking the passageway in the garage. LPA toured the outside grounds. There was shading and sufficient seating for the clients. LPA observed one exit gate was not self-latching. LPA observed that the client bedrooms had all required elements with ample lighting. LPA observed the floor of the shared client bathroom had accumulation of debris that will require a deep cleaning, the wall by the toilet had a hole, and a sharp metal object was exposed. Showers, faucets, and toilets were sanitary and in operating condition. The hot water temperature measured at 118.2, 113.9, and 113.1 degrees Fahrenheit in all bathrooms. There were sufficient and clean supply of linens. LPA observed ample two-day supply of perishables and seven-day supply of non-perishables. LPA observed the emergency food/water. The carbon monoxide and smoke detectors were tested and operational. One auditory device in the medication office was not operating at the time of the visit. The fire extinguisher was securely mounted and serviced on June 29, 2023. Medications, sharps, and toxins were locked and inaccessible to the clients.The following items were all posted and available for review: an incomplete Emergency Disaster Plan (LIC610D), food menu, client rights, Complaint Poster (PUB475) posted in the entry way. LPA reviewed five out of the five client files/medications and three staff files during today's visit. A medication discrepancy was observed during the review of the Medication Log for Client #1. LPA and PD Crawford reviewed the client's funds and noted that the expenses were not being updated into the facility's system.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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Document Has Been Signed on 03/20/2024 07:10 PM - It Cannot Be Edited


Created By: Jessica Cho On 03/20/2024 at 06:14 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81075(o)(4)
81075 Health-Related Services o) For each client that the licensee determines there is a need, a licensee shall develop an individual medication-management plan provided all of the following conditions are met: (4) "The licensee shall ensure that a log is maintained each time medication is taken by the client..."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review with the Program Director, the facility did not ensure an accurate record of medications administered was maintained than what was actually taken for C1which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Program Director stated that an in-service training regarding the administration and documentation of medications will be conducted, PD to provide proof of training as well to submit an Acknowledgment of Understanding for the said deficiency to LPA via email by POC due date.
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:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER
FACILITY NUMBER: 306005701
VISIT DATE: 03/20/2024
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Program Director Crawford was advised on the following items: to repair or replace the battery of the auditory device in the medication office and one exit gate, to declutter/organize the items in the garage, organize the pantry items and correctly label the expiration dates on the opened food items, deep clean the kitchen drawers and floor of the shared client bathroom and to remove the metal object attached to the bathroom wall and to patch the hole, to complete the LIC610D in detail, to accurately document the medications on the medication log, and dispense the medication from the corresponding calendar date from the bubble pack.

Based on today's observations, one deficiency is being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. Technical Advisories are also issued.

An exit interview was conducted with Program Director Andrew Crawford, and a copy of this report including the LIC9099C, LIC9099D, Technical Advisories, and the appeal rights were issued at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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