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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005961
Report Date: 06/14/2022
Date Signed: 06/15/2022 08:27:20 AM


Document Has Been Signed on 06/15/2022 08:27 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:ROSSMOOR SUNSHINE VILLA - SALMONFACILITY NUMBER:
306005961
ADMINISTRATOR:RESURRECCION, FLORMINEFACILITY TYPE:
740
ADDRESS:2971 SALMON DR.TELEPHONE:
(562) 895-0772
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 6DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Licensee RICARDO BANOSTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Licensee Ricardo Banos and explained the reason for the visit.

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. All residents appeared clean and well taken care of. 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 required components. Facility is taking residents temperatures and documenting results.
LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies.
In addition, LPA Frank tested the hot water temperature, which measured 112.4 degrees F in resident
bathroom. Resident areas were noted to be a comfortable temperature.
Smoke 6and bathrooms are operable, facility has water fire sprinklers throughout the facility. The facility also has fire extinguisher that was mounted and charged. LPA Frank 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 observe the facility to be clean and in good repair.
LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808)
Mitigation Plan and 3) 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: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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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