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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006015
Report Date: 12/08/2021
Date Signed: 12/08/2021 01:40:03 PM

Document Has Been Signed on 12/08/2021 01:40 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:SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER, LLCFACILITY NUMBER:
306006015
ADMINISTRATOR:VILLARREAL, MICHAELFACILITY TYPE:
772
ADDRESS:24751 ARGUS DRTELEPHONE:
(949) 533-3046
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
12/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Michael VillarealTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez made an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility was greeted and granted entry by applicant.

An initial application to operate a Social Rehabilitation Facility application, for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was submitted to CCLD on 05/13/2021. Average stay will be 20-25 days.

Structure:
The facility is a one-story house with an attached garage with 3 client’s bedrooms which are shared for 2 clients per bedroom, 1 living room, 1 dining room, a restaurant style open kitchen, 2 bathrooms, 1 staff office, laundry room, and 1 therapy room. The client’s bedrooms are spacious and will easily accommodate the client’s furnishings. There is a large back yard with 2 exit ways on each side of the house with shaded patio area for clients seating.

Signal system:
Central air/heating system installed with a central panel to control entire house.

Bedrooms Residents:
Bedrooms are for 6 clients. Bedrooms will accommodate 6 clients with all rooms being 3 shared rooms.

Bedrooms Staff:
No staff bedroom, no live-in staff.

CONTINUED on LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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 3
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER, LLC
FACILITY NUMBER: 306006015
VISIT DATE: 12/08/2021
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Bathrooms:
All bathrooms have a working toilet, wash basin, and a shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the hallway storage upstairs.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate food supply to meet regulations.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
Gas four-burner stove, single oven, 1 refrigerator, dish washer, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients will be stored in a locked cabinet.

Water Temperature:
Tested and recorded the water temperature measures 120.2 Fahrenheit degrees in all restrooms.

CONTINUED on LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER, LLC
FACILITY NUMBER: 306006015
VISIT DATE: 12/08/2021
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Medications, First-Aid Kit & Book:
Medication and first aid kits will be stored in a locked storage cabinet in office space inaccessible to clients.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in office. Facility will also have records electronically.

Pool/Jacuzzi & Pets:
No bodies of water in facility.

Fire Extinguisher:
Mounted in wall of dining room dated June 08, 2021.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client’s use, commensurate with the plan of operation.

Fire clearance:
Was approved on 07/29/2021.

Component III:
Conducted at the Pre-Licensing tele-visit, information provided about how to operate the facility within substantial compliance.

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the client. This notification may be done by phone, email or fax.

All items reviewed during the visit are in compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor.
Exit interview was conducted and a copy of this report was left with applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC809 (FAS) - (06/04)
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