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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006093
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:54:29 PM

Document Has Been Signed on 04/07/2022 03:54 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:SUNRISE GUEST HOME 3FACILITY NUMBER:
306006093
ADMINISTRATOR:OLTEANU, CLAUDIAFACILITY TYPE:
735
ADDRESS:2000 CALLE CANDELATELEPHONE:
(949) 232-9619
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 4DATE:
04/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Claudia OlteanuTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Lydia Martinez made a visit to the facility to conduct an announced Pre-Licensing evaluation. Upon arrival, LPA met with Applicant Claudia Olteanu and Staff Elena Roatis. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU) for a Capacity of 6 (3 Ambulatory, 2 non-Ambulatory and 1 Bedridden) clients. Facility is an existing facility and 4 clients reside at the facility. Clients were at Program during today's visit. The Fullerton Fire Department conducted a Fire Safety Inspection on 11/18/2021 and granted a Fire Clearance. A tour of the physical plant was conducted inside and out at approximately 9:05 AM with Applicant and Staff and the following was observed:
Structure:
Facility is a one story house with 5 bedrooms and 3 bathrooms. Bedroom #1 is designated as Bedridden and Bedroom #3 is for 2 non-ambulatory, and Bedroom #5 is designated for staff. There is a kitchen, family room,, dining area, and living room.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Clients:
The client bedrooms accommodate clients' furnishings and meet Title 22 regulation at this time.
Bathrooms:
The 3 bathrooms have a working toilet, wash basin, and shower. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies
Adequate supply of linens and hygiene items were observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Ombudsman poster, Personal Rights and the See Something Say Something are posted.
Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables and fruits and vegetables were observed.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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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 3
FACILITY NUMBER: 306006093
VISIT DATE: 04/07/2022
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Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
The Fire Extinguisher was mounted and fully charged.
Appliances:
Refrigerator/freezer and microwave were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Are locked and inaccessible to clients
Water Temperature:
Hot water temperature is tested and is within regulatory requirements.
Medications, First Aid Kit & Manual:
First Aid kit with guide is stored in the medication cabinet. Medication is stored in locked kitchen cabinet
Client and Staff Files:
Kept in a locked kitchen cabinet.

A Component III Orientation will be waived as the Applicant is a current Licensee and operates two other facilities. The Applicant demonstrated a clear, concise and comprehensive knowledge of medication protocols, documentation and preventative protocols.

The Pre-Licensing inspection has been completed. All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist.



An exit interview was conducted and a copy of this report will be emailed.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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