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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005917
Report Date: 06/06/2022
Date Signed: 06/06/2022 05:14:42 PM


Document Has Been Signed on 06/06/2022 05:14 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:SUNRAYS BOARD & CAREFACILITY NUMBER:
306005917
ADMINISTRATOR:TINIO, RAYMONDFACILITY TYPE:
740
ADDRESS:7120 FILLMORE DR.TELEPHONE:
(562) 310-5772
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Carel Velarde, Edita Tersoro TIME COMPLETED:
05:25 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
Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Carel Velarde and stated the purpose of this visit. LPA Tapia reviewed Facility Personnel Report and noticed that staff Carel Velarde is not associated with the facility. LPA Tapia contacted Administrator to informed them that all staff need to be associated to the facility. Administrator stated he is out of town and could not come to the inspection. LPA Tapia reminded Administrator of their responsibilities as an Administrator. Administrator filled out LIC 9182 for Carel Velarde and staff filled out LIC 508. Facility was unable to associate staff Carel Velarde to the facility. Administrator filled out LIC 9182 for Edita Tersoro and was able to associate Edita Tersoro to facility. LPA Tapia observed Carel Velarde leave the facility prior to LPA leaving the facility.

The facility is licensed for six non-ambulatory one of which may be bedridden and a hospice waiver for six. This facility offers Residential Care for the Elderly and Dementia.

For this visit, a deficiency was noted in areas observed and a Civil Penalty was issued. Due to time constraints LPA will return at a later date.

LPA Tapia conducted an exit interview with staff and copy of this report was explained and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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 2


Document Has Been Signed on 06/06/2022 05:14 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: SUNRAYS BOARD & CARE
FACILITY NUMBER: 306005917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(1)
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:

(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of one which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
1
2
3
4
Administrator removed individual during visit.
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 SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2