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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005832
Report Date: 07/29/2022
Date Signed: 08/22/2022 10:31:30 AM


Document Has Been Signed on 08/22/2022 10:31 AM - 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:SUMNER BOARD AND CAREFACILITY NUMBER:
306005832
ADMINISTRATOR:BUMANGLAG, ARVINFACILITY TYPE:
740
ADDRESS:8652 SUMNER PLTELEPHONE:
(714) 350-1052
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 6DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Licensee Arvin Bumanglag TIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by Licensee Arvin Bumanglag and reason for visit was explained.

LPA Frank toured the facility. There are 6 residents residing in the facility and no active COVID-19 cases. LPA observed 6 residents on site appeared clean and well taken care and 3 residents are receiving hospices care. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all confirmed food supply: 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet. LPA observed Facility’s physical plant, hallways appears to be clean and free of debris, free of odor. Sufficient lighting observed throughout the facility. No bodies of water, weapons or ammunition on premises. In addition, LPA Frank tested the hot water temperature, which measured 109.1 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. Smoke detectors and carbon monoxide detector were tested and are operational. Fire extinguishers were fully charged. Fire drill was conducted on 2/15/22. Facility stove, oven, microwave, refrigerator, washer and dryer are clean and operational. LPA observe the facility to be clean and in good repair.
LPA Frank reviewed : Emergency Disaster Plan (LIC610E); LIC 9020A Client Roster; LIC 808) Mitigation Plan and Current Liability Insurance; Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500); Based on the observations made during today’s visit, no deficiencies are being cited in area inspected. This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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