306006090-3-21-2022-22-AS-RMAZ-CCQP3Y-20220321105818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006090
Report Date: 03/21/2022
Date Signed: 03/21/2022 10:58:31 AM

Document Has Been Signed on 03/21/2022 10:58 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:	SUNRISE GUEST HOME 1		FACILITY NUMBER:	306006090
ADMINISTRATOR:	OLTEANU, CLAUDIA		FACILITY TYPE:	735
ADDRESS:	323 E BLUEBELL PLACE		TELEPHONE:	(949) 232-9619
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY: 6		CENSUS: 6	DATE:	03/21/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Claudia Olteanu		TIME COMPLETED:	11:05 AM

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) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility was greeted by applicant and granted entry. An initial application to operate an Adult Residential Facility (ARF), for (6) capacity, (3) ambulatory, (2) non-ambulatory, and (1) bedridden client was submitted to CCL on 10/12/2021. Structure: The facility is a one-story house with an attached garage with 4 bedrooms, 1 office, 1 living room, 1 dining room, and a restaurant style open kitchen. The clients 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 seating area for clients. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Clients: Bedrooms are for 6 clients. Bedrooms will accommodate 6 clients with all rooms being shared. Bedrooms Staff: 1 bedroom designated for live-in staff. Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower. CONTINUED on LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

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 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: SUNRISE GUEST HOME 1	FACILITY NUMBER: 306006090
	VISIT DATE: 03/21/2022

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
26
27
28
29
30
31
32

Linens & Hygiene Supplies:
Adequate supply of linen stored in locked storage cabinet in hallway of bedrooms.

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 supply of 7-day non-perishable and 2-day perishables are stored in the kitchen.

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

Appliances:
Four-burner electric stove, single oven, 2 refrigerator (1 in attached garage), dish washer, 2 microwaves, 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 are locked in storage cabinet.

Water Temperature:
Tested and recorded the water temperature measures 114.8 Fahrenheit degrees in all restrooms.

Medications, First-Aid Kit & Book:
Medication stored in storage cabinet locked in dinning room inaccessible to clients. First aid kits are stored and located in with medication.

CONTINUED on LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

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: SUNRISE GUEST HOME 1	FACILITY NUMBER: 306006090
	VISIT DATE: 03/21/2022

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
26
27
28
29
30
31
32

Resident & Staff Files:
Resident and Staff records will be kept locked in medication storage cabinet.

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

Fire Extinguisher:
Mounted in wall of kitchen dated February 28, 2022.

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

Fire clearance:
Was approved on 11/30/2021.

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

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 the applicant.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3