306005917-6-13-2024-22-AS-JHAY-D67W4T-20240613165805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005917
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:58:57 PM

Document Has Been Signed on 06/13/2024 04:58 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:	SUNRAYS BOARD & CARE		FACILITY NUMBER:	306005917
ADMINISTRATOR:	MACRINA JABONERO		FACILITY TYPE:	740
ADDRESS:	7120 FILLMORE DR.		TELEPHONE:	(714) 723-0169
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 4	DATE:	06/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Raymond Tinio Macrina Jabonero		TIME COMPLETED:	05:05 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 Analysts (LPA) Jerome Haley conducted an unannounced visit to the facility to complete the required Annual inspection. LPA Haley met with Licensee/Administrator Raymond Tinio and toured the facility. The facility has a capacity of 6, of which 6 can be non-ambulatory and 1 may be bedridden. The facility has a Hospice waiver for 6. The facility telephone number 714.723.0169. Structure: The facility is one level structure with four bedrooms. Currently one bedroom is vacant and one bedroom is being shared by a husband and wife. Kitchen: Clean and organized. Sharps locked in a drawer. A perishable food supply was observed in the refrigerator and freezer. Non-perishable food supply was observed in the cabinets. Stove/Appliances: There’s one stove with 4 burners and a warmer, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational. Toxins: All cleaning supplies and chemicals are locked under the kitchen sink. Medications, First-Aid Kit: Resident medications are stored in a locked cabinet in the kitchen. There’s a first aid kit with all the required elements on a stand right below the sign in book as soon as you walk in the front door. Resident & Staff Files: The Resident and Staff Records are kept locked in a desk drawer in the office area in between the living room and kitchen areas. Bedrooms: Resident bedrooms were clean, organized and were in compliance with regulation guidelines. Bathrooms: There are two bathrooms and both bathrooms have a working toilets, wash basin and shower. Grab bars were tightly secured to the wall. Hot Water: Hot water was measured in the range of 105 - 107.1 degrees F. Continued on LIC809C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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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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: SUNRAYS BOARD & CARE	FACILITY NUMBER: 306005917
	VISIT DATE: 06/13/2024

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Hygiene Supplies: The facility has an adequate supply of hygiene items on hand.
Linens, Hygiene, Emergency Supplies: Additional linens for each resident are stored in a closet right next to the front door.
Emergency Evacuation Drills: The most recent evacuation drill was conducted April 12, 2024, and are conducted quarterly for all staff.
Medication Review: There are currently four residents in the facility and medication was reviewed for 2 of 4 residents.
Resident File Review: A file review was completed for all four residents.
Staff File Review: 4 staff files were reviewed during the visit.
Garage: The garage is used to store facility items. Walkways are free of obstruction. A washer and dryer was observed. Some of the items being stored in the garage are walkers, wheelchairs, N95 mask, and a few old mattresses.
Backyard: Clean, organized and walkways are free of obstruction. There are two tables with chairs under a shaded patio. Side exit gates are self-closing and self-latching.
Smoke Detectors/Carbon Monoxide Detectors: Smoke detectors and the carbon monoxide detector tested operational. There’s a fully charged fire extinguisher mounted on the wall in the office area.
Misc (P&I): N/A. The facility does not manage any of the resident’s money.
Activities, Recreation, Reading Material, etc: Exercises and ball toss are the primary activities. There is a bingo game and the facility celebrates resident birthdays.
Citation(s) & TV/TA: No citations of technical violations will be issued as a result of todays inspection.
Exit Interview: Exit interview was conducted, and a copy of this report were provided to Licensee/Administrator Raymond Tinio and Administrator Macrina Jabonero.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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